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ON    DISEASES 


LUNGS  AND   PLEURiE 

IKCLUDING 

TUBERCULOSIS  AND    MEDIASTINAL  GROWTHS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/ondiseasesoflungOOpowe 


PLATE    XXVIII. 


The  Gidematons  Pleura — a  stage  in  the  formation  of  the 
thickened  Pleura. 


Frontispiece 


THE  CEDEMATOUS  PLEURA— A  STAGE  IN  THE 
FORMATION  OF  THE  THICKENED  PLEURA 

The  specimen  shows  a  section  through  the  left  lung.  The 
upper  lobe  is  much  shrunken  and  shows  advanced  pulmonary 
tuberculosis,  including  a  large  cavity.  Extensive  tuberculous 
disease  is  also  present  in  the  lower  lobe.  Over  the  upper  lobe  and 
in  the  great  fissure,  the  pleural  layers  are  seen  to  be  separated 
and  the  space  crossed  by  fine  vascular  loops  ;  the  interveriing 
meshes  are  filled  with  serous  fluid,  and  the  whole  presents  a 
gelatinous  appearance.  As  yet  the  pleural  membrane  itself  is 
hardly  at  all  thickened.  The  dense  fibrous  thickening  which 
results  at  a  later  stage  may  be  seen  in  Plates  XXX.  and  XXXI. 

From  a  boy  aged  seventeen,  who  died  from  chronic  pulmonary 
tuberculosis  with  terminal  miliary  tuberculosis  of  lungs  and 
kidneys,  and  with  tuberculous  lesions  in  the  larynx  and  intestines. 

(From  the  Museum  of  the  Brompton  Hospital 
f  natural  size.) 


PLATE  XXVIII  .    • 


ON    DISEASES 

OF   THE 

LUNGS  AND  PLEURy^ 

INCLUDING 

TUBERCULOSIS  ^  MEDIASTINAL  GROWTHS 

BY 

SIR  R.  DOUGLAS  POWELL,  Bart. 

K.C.V.O.,  M.D.  LoND.,  F.R.C.P. 
Hon.  D.Sc.  Oxon  ;  M.D.  Dublin;  F.R.C.P. I.,  LL.D.  Aberd.  and  Birm. 

PHYSICIAN    IN    ORDINARY   TO    H.ll.    THE    KING  :    CONSULTING    PHYSICIAN    AND    EMERITUS   LECTURER 

ON   MEDICINE   TO   THE   MIDDLESEX    HDSl'ITAL  ;    CONSULTING    PHYSICIAN   TO    THE    HOSPITAL 

FOR   CONSUMPTION    AND    DISEASES    OF    THE   CHEST    AT    BKOMPTON,    AND   TO   THE 

VENTXOR   HOSPITAL  ;    KNIGHT    OF    CiRACE   OF   THE   ORDER    OF    ST,   JOHN 

OF   JERUSALEM 

AND 

P.  HORTON-SMITH   HARTLEY 

C.V.O.,  M.A.,  :\I.D.  Cantab..  F.R.C.P. 

LATE    FELLOW   OF    ST,    JOHN's   COLLEGE,    CAMBRIDGE  ;    PHYSICIAN   WITH    CHARGE    OF    OUT-PATIENTS 
TO   ST.    BARTHOLOMEW'S   HOSPITAL  ;  SENIOR    PHVSICIAN   TO    THE   HOSPITAL    FOR   CONSUMP- 
TION  AND   DISE.^SES   OF   THE   CHEST    AT   BROMPTON  ;    MEMBER   OF    COUNCIL   (l.ATE 
HON.   SEC.)   OF    THE   KING   EDWARD    VII.    SANATORIUM  ;    CONSULTING 
PHYSICI.^N   TO    THE    DANESWOOD    SANATORIUM 


SIXTH  EDITION 
WITH  ILLUSTRATIONS 


PHILADELPHIA 

P.  BLAKISTON'S   SON   &   CO. 

1921 


7^-^- . 


/        I 


Printed  in  England 


PREFACE 

TO  SIXTH  EDITION 

Another  nine  years  have  elapsed  since  the  last  edition  of  this 
work  and  twenty-eight  years  since  the  appearance  of  the 
fourth  edition. 

In  the  course  of  this  time  the  last  word  has  been  said  on 
antiseptic  methods  in  surgery  and  more  tardily  in  medicine, 
methods  upon  which  so  much  of  modern  treatment  of  pul- 
monary disease  is  based,  and  in  still  greater  degree  its 
prevention.  During  this  period  bacteriology  has  made  great 
strides,  and  has  succeeded  in  elucidating  many  problems 
dealing  with  pathological  and  therapeutic  action.  If  in  the 
latter  respects,  though  rich  in  other  fields  of  work,  bacterio- 
logical research  has  been  less  fruitful  in  practical  results  in 
the  field  of  lung  diseases,  it  must  be  gratefully  acknowledged 
that  such  investigations  have  served  to  deepen  our  insight  into 
the  pathology  of  these  diseases  and  the  problems  of  immunity, 
and  have  in  no  slight  degree  rendered  more  clear  our  outlook 
for  future  treatment. 

As  in  recent  editions,  fairly  full  references  to  literature  on 
the  subjects  dealt  with  have  been  appended  to  each  chapter,  but 
the  authors  have  not  hesitated  to  express  as  definitely  as  pos- 
sible their  own  conclusions  after  due  consideration  of  the 
views  of  others.  Some  of  the  older  references  have  also  been 
retained  in  view  of  historic  interest  and  continuity. 

Several  new  clinical  cases  have  been  introduced  in  illustra- 
tion of  some  of  the  varieties  of  phthisis,  and  also  of  other 
diseases,  but  many  of  the  old  cases  have  been  preserved  as 
clinical  pictures  the  outlines  of  which  have  not  faded  with 
time. 

Reference  to  tuberculin  has  been  considerably  shortened 


VI  PREFACE    TO    SIXTH    EDITION 

in  acceptance  of  the  lessened  value  attached  to  its  use  except 
in  special  cases.  In  prescribing"  this  remedy  the  cubic  milli- 
metre has  been  adopted  as  the  basis  for  dosage  instead  of  the 
cubic  centimetre  as  in  former  editions. 

New  chapters  have  been  added  on  Gunshot  Wounds  of  the 
Chest,  Chylothorax,  Massive  Collapse  of  the  Lung-,  Sporo- 
trichosis, and  Artificial  Pneumothorax;  and  surgicat methods 
have  been  more  fully  dealt  with  in  connection  with  certain 
diseases. 

The  Authors  haxe  gratefully  to  acknowledge  the  help  of 
Professor  Bainbridge,  Dr.  H.  M.  Gordon,  Dr.  W.  Jobson 
Home,  Dr.  L.  S.  T.  Burrell,  and  Professor  Gask  in  revising 
the  proofs  on  certain  subjects  and  giving  valuable  criticism 
and  suggestions  thereupon. 

Professor  Karl  Pearson  and  Dr.  Brownlee  have  also 
favoured  the  Authors  with  valuable  advice  in  connection  with 
the  aetiology  of  phthisis,  and  have  revised  and  completed  to 
date  the  diagrams  illustrating  its  epidemiology  and  prevalence. 
Recent  figures  showing  the  standardised  death-rate  from 
phthisis  have  been  courteously  supplied  by  the  Registrar- 
General. 

The  Authors'  thanks  are  also  due  to  the  Medical  Research 
Council  for  permission  to  reproduce  drawings  from  their 
publications  which  are  referred  to  in  the  text. 

The  Index  of  the  volume  has  been  somewhat  shortened 
in  the  able  hands  of  Miss  A.  Newbold,  and  finally  the  Authors 
have  most  gratefully  to  acknowledge  the  services  of  Miss  E.  F. 
Parry  in  revising  and  arranging  the  text  of  the  whole  book. 

LoXDOX, 

October,  1920. 


PAGE 


CONTENTS 


CHAPTER  I 

ON   SOME   ESSENTIAL   POINTS    IN    THE   ANATOMY   AND 
FUNCTIONS    OF    THE    LUNGS 

The  anatomy  of  the  lungs.  Pulmonary  circulation.  Respiratory 
function  and  mechanism.  Respiration  in  the  new-born  child. 
The  contractile  powers  of  the  lungs ;  their  residual  tension. 
Elastic  resilience  of  chest  walls  acting  as  an  inspiratory  force. 
Schema  for  demonstrating  the  respiratory  movements.  Statics 
and  d3mamics  of  respiration.    Lymphatics  and  nerves  of  the  lung 


CHAPTER  n 

THE  PHYSICAL  EXAMINATION   OF  THE  CHEST 

The  chest;  its  shape,  measurements  and  mobility.  Pneumatometry 
Spirometry.  Vital  capacity  :  influence  of  body-weight  thereon. 
Topography  of  the  chest,  with  anatomical  figures    -  -  -       22 

CHAPTER  ni 

THE    PHYSICAL    EXAMINATION    OF    THE    CHEST    (continued) 

Physical  exploration.  Inspection,  movements,  etc.  Palpation ; 
vocal  fremitus.  Methods  and  theory  of  percussion.  Table  of 
terms.  International  nomenclature  of  physical  signs.  Ausculta- 
tion. Breath-sounds,  healthy  and  morbid ;  their  probable 
mechanism  and  significance.  Adventitious  sounds.  Voice- 
sounds.     Auscultatory   percussion.     Roentgen   rays  -  -      23 

CHAPTER  IV 

EXAMINATION    OF    THE    SPUTUM 

Main  sources.     Quantity;    reaction;   consistence;   colour.     Bronchial 
casts.     Microscopic    examination.     Red    and    white    blood-cells. 
Epithelium.     Elastic     fibres.     Curschmann's     spirals.     Tonsillar 
casts.     Crystals,   Micro-organisms,     Adventitious  and  extraneous 
matters       -  -  -  -  -  -  -  -  -      66 

vii 


viii  CONTENTS 

CHAPTER  V 

DEFORMITIES   AND    DISEASES    OF    THE    CHEST    WALLS 

I'AGE 

The  pigeon  breast.  The  rickety  and  alar  chests.  Pleurodynia. 
Aponeurotic  rheumatism.  Myalgia.  Intercostal  neuralgia. 
Herpes  zoster.  Periostitis,  perichondritis,  and  osteo-myelitis. 
Costal  Abscess.     Fascial  creaking        -  -  -  -  -       7^ 

CHAPTER  VT 

DISEASES    OF    THE    PLEURA  :    PLEURISY 

Position  and  connections  of  the  pleura  ;  its  lymphatic  system.  Clas- 
sification of  pleurisies.  Fibrinous  pleurisy  :  pathology  and 
symptoms.     Diaphragmatic     variety  :     symptoms.     Treatment      -      85 

CHAPTER  Vn 

SERO-FIBRINOUS    AKD    HEMORRHAGIC    PLEURISY 

Acute  sero-fibrinous  pleurisy  :  aetiology ;  evidence  of  tuberculous 
origin  of  primary  cases;  cytological  and  chemical  characters  of 
the  fluid ;  symptoms ;  signs — cardinal,  supplementary,  and  those 
indicative  of  nature  of  fluid ;  diagnosis ;  prognosis ;  treatment. 
Paracentesis  thoracis: — selection  of  spot;  method  of  perform- 
ing ;  the  syphon ;  Potain's  aspirator.  Chronic  sero-fibrinous 
effusion ;  treatment  by  oxygen-replacement.  Hsemorrhagic 
pleurisy      -  -  -  -  -  -  -  -  -      90 

CHAPTER  Vni 

SUPPURATIVE    PLEURISY 

J^tiology  and  bacteriology ;  symptoms  and  physical  signs ;  fectoril- 
oquie  afhoniqtie;  pulsation  of  the  fluid.  Special  varieties  of 
empyema  :  foetid,  tuberculous,  and  encysted  or  localised.  Diag- 
nosis;    prognosis;    treatment.    -  -  -  -  -  -     118 

CHAPTER  IX 

PNEU.MOTHORAX  :     HYDRO-    AND    PYO-PNEUMOTHORAX 

^Etiology.  The  tuberculous  variety  :  nature  of  the  opening,  of  the 
gas,  and  of  the  effusion ;  symptoms ;  physical  signs — hyper- 
resonance,  alteration  of  breath-sounds,  displacement  of  heart; 
X-ray  appearances ;  course  and  prognosis  ;  diagnosis  ;  treatment. 
Illustrative  case  of  pyo-pneumothorax  of  long  duration     -  -     133 


CONTENTS  IX 

CHAPTER  X 

HEMOTHORAX — GUNSHOT  WOUNDS   OF  THE  CHEST 

PAGE 

Hasmothorax  in  civil  life  :  aetiology,  symptoms,  physical  signs,  and 
treatment. 

Haemothorax  following  wounds  of  the  chest.  S3miptoms  of  onset ; 
peculiarity  of  physical  signs ;  course  varying  according  as  the 
haemothorax  remains  sterile  or  not.  Treatment  of  sterile  haemo- 
thorax :  question  of  paracentesis  ;  prognosis.  Tre<Ltment  of  in- 
fected cases.  Operative  treatment  of  gunshot  wounds  of  the 
chest  with  a  view  to  prevent  the  development  of  sepsis  :  illustra- 
tive case  showing  the  value  of  the  method  in  selected  cases  -     157 

CHAPTER  XI 

CHYLOTHORAX 

Definition.  The  true  chylous  and  the  pseudo-chylous  varieties. 
Table  showing  points  of  distinction,  including  the  presence  of 
free  fat,  and  of  the  "  lecithin-globulin  complex."  .Etiology  of 
each  form.  Symptoms,  prognosis  and  treatment.  Illustrative 
case  of  the  pseudo-chylous  variety      .  .  .  .  .     166 

CHAPTER  Xn 

BRONCHITIS — BRONCHIAL  CATARRH 

Definition ;  aetiology ;  bacteriology ;  morbid  anatomy.  Clinical 
varieties  :  (i)  Acute  forms  :  tracheo-bronchitis,  capillary,  acute 
asthenic,  and  purulent  bronchitis.  Illustrative  case  of  the  acute 
asthenic  variety.  Treatment  of  acute  bronchitis.  (2)  Chronic 
bronchitis  :  aetiology ;  symptoms ;  physical  signs ;  treatment. 
(3)  Peculiar  forms  :  pituitous  catarrh ;  bronchitis  sicca ;  plastic 
bronchitis  -  -  -  -  -  -  -  -176 

CHAPTER  Xni 

NARROWING   AND    DILATATION    OF   THE    BRONCHI 

Narrowing  of  the  bronchi  :  aetiology ;  resulting  condition  of  lungs ; 
symptoms  and  signs ;  treatment. 

Dilatation  of  the  bronchi — bronchiectasis  :  age-incidence ;  varieties, 
cylindrical  and  sacculated ;  causes  of  bronchial  dilatation ;  symp- 
tomatology ;  course ;  diagnosis  and  treatment.  Pulmonary  osteo- 
arthropathy. 

Acute   bronchiectasis   or   bronchiolectasis  :    the    "honeycomb    lung"     202 


CONTENTS 


CHAPTER  XIV 

ON    FOREIGN    BODIES    IN    THE    AIR-PASSAGES,    AND 
ESPECIALLY    IN    THE    BRONCHI 


PAGE 


Etiology  :  age  and  sex.  Table  showing  nature  and  position  of  the 
foreign  body  in  210  cases.  Resulting  changes  in  the  lungs. 
Symptoms  and  physical  signs  illustrated  by  cases.  Diagnosis. 
Treatment  :   the  value  of  bronchoscopy  ...  -     223 


CHAPTER  XV 

ASTHMA 

Definition.  Relation  of  the  disease  to  bronchial  spasm ;  facts  and 
arguments  in  support  of  this  view.  ^Etiology  :  exciting  causes — 
direct,  reflex  and  central  irritation.  Asthma  often  of  anaphylactic 
origin,  due  to  hypersensitiveness  to  some  protein,  present  in 
poUen,  animal  hair,  food  or  bacteria  :  the  skin  test.  Clinical 
varieties  :  essential  or  true  spasmodic  asthma,  catarrhal  or  bron- 
chitic,  dust,  hay,  nasal,  peptic,  cardiac  and  ursemic  asthma. 
Symptomatology ;  mode  of  attack ;  physical  signs ;  prognosis. 
Treatment  :  specific ;  climatic  ;  medicated  airs  and  baths ;  regu- 
lation of  the  digestive  functions ;  attention  to  other  sources  of 
peripheral  irritation;  treatment  of  the  paroxysm.  Use  of  vac- 
cines as  a  prophylactic  measure.  Danger  of  the  use  of  diph- 
theritic and  other  sera  in  asthmatic  subjects  -  -  -     242 

CHAPTER  XVI 

PULMONARY    VESICULAR    EMPHYSEMA 

Definition.  Pathology  :  compensatory  changes.  Etiology  :  dis- 
cussion of  the  different  views  held  in  regard  to  its  production. 
Varieties  of  the  disease,  (i)  Local  pulmonary  emphysema. 
(2)  General  vesicular  emphysema  :  large-lunged  and  small-lunged 
or  senile  varieties.  Illustrative  case;  tracings  of  thoracic  move- 
ment. Treatment  :  general  and  climatic ;  asrotherapeutics ; 
surgery. 

Interstitial  or   interlobular   emphysema     -----    269 

CHAPTER  XVII 

PNEUMONIA 

Definition  of  the  disease.  Ji^tiology.  Bacteriology  :  various  types  of 
the  pneumococcus.  Pathology  and  morbid  anatomy  :  the  three 
stages.  Symptoms  ;  description  of  a  case ;  diagnosis.  Varieties  : 
septic  pneumonia,  illustrative  case ;  migratory,  creeping  or  wan- 
dering  pneumonia ;   latent   pneumonia.      Unusual   terminations  : 


CONTENTS  XI 

PAGE 

delayed  resolution ;  purulent  infiltration ;  abscess ;  gangrene. 
Implication  of  other  organs  :  table  showing  the  more  important 
complications.  Prognosis.  Treatment  of  the  different  stages. 
Specific  treatment  -...-..    286 


CHAPTER     XVIII 

BRONCHO-PNEUMONIA 

Definition.  ^Etiology.  Bacteriology.  Morbid  anatomy.  Varieties 
of  the  disease  :  primary  broncho-pneumonia ;  secondary  broncho- 
pneumonia, the  disseminated  and  confluent  forms.  Symptoms, 
physical  signs  and  treatment. 

Influenzal  pneumonia  ---....    323 


CHAPTER  XIX 

CHRONIC    INTERSTITIAL    PNEUMONIA    OR    CIRRHOSIS    OF    THE 
LUNG PNEUMOKONIOSIS 

Interstitial   pneumonia  :    not    usually    a    primary    disease ;    aetiology ; 

morbid  changes   in  the  lung  ;   microscopical  characters ;  clinical 

features ;  diagnosis. 
Pneumokoniosis  :    aetiology ;   symptoms   and  course ;   illustrative  case 

of  gold-miner's  phthisis  ......    335 


CHAPTER  XX 

COLLAPSE    OF    THE    LUNG — MASSIVE    COLLAPSE 

Causes  of  simple  pulmonary  collapse. 

Massive  collapse.  Tvi^o  varieties  :  (a)  Group  I.,  due  to  direct 
paralysis  of  respiratory  muscles,  as  in  diphtheria,  (ib)  Group  II., 
of  reflex  inhibitory  origin,  following  wounds  or  abdominal  opera- 
tions. Mechanism  of  the  collapse.  Signs  and  symptoms  of  each 
group.     Prognosis.     Treatment  -  -  .  .  .    344 


CHAPTER  XXI 

CEDEMA  OF  THE  LUNGS 

Definition.  Two  varieties  of  the  condition  :  (i)  Chronic  pulmonary 
cedema  :  aetiology ;  morbid  anatomy ;  symptomatology ;  prognosis 
and  treatment.  (2)  Acute  pulmonary  oedema :  description  of 
seizure;  characteristic  expectoration;  aetiology,  prognosis  and 
treatment.  Cases  resulting  from  inhalation  of  poison  gases,  such 
as  chlorine  and  phosgene,  used  during  the  war      -  -  -    352 


Xii  CONTENTS 

CHAPTER  XXII 

ABSCESS    AND    GANGRENE    OF    THE    LUNG 

PAGE 

Suppuration  in  the  lung  tissue ;  etiology ;  varieties ;  symptoms,  signs 
and  treatment.  Indications  for  surgical  intervention.  Steps  in 
the  operation. 

Gangrene  of  the  lung  :  circumscribed  and  diffused ;  aetiology  and  bac- 
teriology; symptoms,  physical  signs  and  treatment  -  -    359 

CHAPTER  XXIII 

HYDATID   DISEASE   OF   THE  LUNGS 

Geographical  distribution.  Age  and  sex  incidence.  Mode  of  en- 
trance of  the  parasite.  Symptoms  and  signs  before  rupture  of 
cyst.  Value  of  X-ray  examination.  Illustrative  cases.  Rupture 
of  cyst  :  symptoms  thereof.  Course  and  treatment  of  the  disease. 
Successful  results  of  operation  .....    367 

CHAPTER  XXIV 

INTRATHORACIC    DERMOID    TUMOURS 

Nature  of  the  disease;  true  dermoids  and  teratomata.  Age  and  sex 
incidence.  Symptoms;  physical  signs;  course  and  treatment. 
Question  of  surgical  intervention.     Illustrative  case  -  -    379 

CHAPTER  XXV 

SYPHILITIC    DISEASE    OF    THE    BRONCHI    AND    LUNGS 

Bronchial  syphilis  :  secondary  and  tertiary  manifestations.  Pul- 
monary syphilis  :  (i)  the  congenital  form,  syphilitic  or  white 
pneumonia;  (2)  the  gummatous  form,  occurring  in  acquired 
syphiUs ;  its  sjonptoms  and  physical  signs.  Illustrative  case 
showing  how  closely  the  latter  variety  may  simulate  tubercu- 
losis.    Treatment.  .  Pulmonary  tuberculosis  in  syphilitic  subjects     385 

CHAPTER  XXVI 

STREPTOTRICHOSIS    (ACTINOMYCOSIS)    OF    THE    LUNG    AND 

PLEURA 

History  of  the  disease.  Morphological  and  other  features  of  the 
parasite.  Distribution  of  the  streptothrix  group  in  nature. 
Morbid  changes  produced  in  the  tissues  by  the  organism.  Chief 
cUnical  features  of  the  disease.  Illustrative  cases.  Diagnosis 
and  treatment      -  -  -  -  -  -  -  -    394 


CONTENTS   .  XUl 

CHAPTER  XXVII 

SPOROTRICHOSIS 

FACE 

Nature  and  distribution  of  the  parasite.  Clinical  manifestations  of 
the  disease.  A  case  of  the  pulmonary  variety.  Diagnosis  and 
treatment  -  -  -  -  -  -  -  -  -     411 

CHAPTER  XXVIII 

ASPERGILLOSIS 

Definition.  Characters  and  botanical  position  of  the  Aspergillus 
fumigatus.  Clinical  features  and  course  of  the  disease.  Method 
of    identifying    the    parasite.     Treatment       -  -  -  -     414 

CHAPTER  XXIX 

PULMONARY  TUBERCULOSIS  :    .-ETIOLOGY 

Present  mortality  from  tuberculosis.  Occurrence  of  the  disease  in 
ancient  civilisations.  Use  of  the  terms  "phthisis"  and  "con- 
sumption." The  Bacillus  tuberculosis :  history  of  its  discovery; 
morphology ;  relation  to  the  streptothrix  group ;  method  of  stain- 
ing ;  biological  characters ;  human,  bovine,  and  avian  varieties  ; 
distribution  in  the  lesions.  Channels  of  infection  :  congenital 
tuberculosis ;  infection  by  inoculation,  inhalation,  and  inges- 
tion. Danger  of  infected  milk.  Relation  of  the  human  and 
bovine  bacilli  to  various  forms  of  human  tuberculosis.  The  ques- 
tion of  contagion.     Marital  or  conjugal  tuberculosis  -  -     419 

CHAPTER  XXX 

PULMONARY   TUBERCULOSIS  :    .ETIOLOGY    {contlnueS) 

Constitutional  liability  :  inherited  tendency  to  phthisis.  Influence  of 
climate;  injury;  social  conditions;  age;  overcrowding;  dusty 
employment;  alcohol;  insanity.     Epidemic  features  of  the  disease     444 

CHAPTER  XXXI 

ON    THE    PATHOLOGY    OF    Pl'LMONARY    TUBERCULOSIS 

Nature  of  the  morbid  processes.  The  occurrence  of  tuberculous 
granulations  and  of  inflammatory  changes.  Caseous  and  fibroid 
degeneration.  The  presence  and  significance  of  organisms  other 
than  the  tubercle  bacillus ;  mixed  and  secondary  infections.  The 
influence  of  the  rigid  chest  wall  and  the  respiratory  movements 
upon  the  lesions  of  phthisis.  Site  and  spread  of  the  disease. 
Hilum  tuberculosis  ..-----     463 


XIV  CONTENTS 


CHAPTER  XXXII 

ON    THE    VARIETIES    OF    PL'LMONARY    TUBERCULOSIS  —ACUTE 
TUBERCULOSIS   OF   THE  LUN'GS 

I'AGE 

Classification  and  synonjms.  Acute,  subacute,  and  chronic  tuber- 
culosis. 

Acute  tuberculosis  of  the  lungs  :  (i)  Confluent  forms,  "  acute  pneu- 
monic phthisis":  physical  signs  and  symptoms;  processes  of 
arrest;  illustrative  cases;  its  relation  to  diabetes.  (2)  Dis- 
seminated form  :  {a)  "  florid  phthisis  "  or  "  galloping  consump- 
tion "  :  characteristic  symptoms,  illustrative  cases,  (b)  Acute 
miliary  tuberculosis  :    illustrative  cases  -  -  .  -     474 

CHAPTER  XXXIII 

ON  SUBACUTE  TUBERCULOSIS  OF  THE  LUNGS 

Pulmonary  tuberculisation  :  morbid  appearances  in  the  lungs;  clinical 

features  and  physical  signs  ;  prognosis  ;  illustrative  case  -  -    497 

CHAPTER  XXXIV 

CHRONIC    TUBERCULOSIS    OF    THE   LUNGS 

Symptoms  and  physical  signs.  Importance  of  an  early  and  repeated 
examination  of  the  sputum.  Descriptive  case.  Prognosis. 
Transition  from  ordinary  chronic  to  fibroid  phthisis ;  case  in 
illustration  -  -  -  -  -  -  -  -     502 

CHAPTER  XXXV 

CHRONIC  TUBERCULOSIS  OF  THE  LUNGS  {Continued)  : 

FIBROID    PHTHISIS 

Meaning  of  the  term  "  Fibroid  Phthisis."  Morbid  changes  in  the 
lungs.  Chief  clinical  features  of  the  disease.  Illustrative  cases. 
Prognosis  -  -  -  -  -  -  -  -     511 

CHAPTER  XXXVI 

TUBERCULOUS    EXCA\'ATION    OF    THE    LUNG — THE    CA\'ITY 
■      STAGE    OF    PHTHISIS 

Stages  in  the  production  of  cavities.  Varieties.  The  recent  cavity  : 
its  method  of  formation  and  physical  signs.  Cases  illustrating 
the  sudden  formation  of  a  vomica  by  the  rupture  of  a  caseous 
abscess.  Theories  to  explain  the  enlargement  of  cavities.  The 
quiescent  cavity  :  signs  and  symptoms.  The  secreting,  and 
ulcerous  cavity     ----....     rji 


CONTENTS  XV 


CHAPTER  XXXVII 


THE    COMPLICATIONS    OF    PULMONARY    TUBERCULOSIS  :  LARYNGEAL, 
AURAL   AND   INTESTINAL   TUBERCULOSIS 


PAGE 


Table  showing  relative  frequency  of  important  complications. 
Laryngeal  tuberculosis  :  very  rarely  primary ;  method  of  infec- 
tion ;  position  of  early  changes  in  larynx ;  symptoms ;  prognosis ; 
diagnosis.  Tuberculous  disease  of  the  middle  ear  :  its  painless 
character  •  prognosis  and  treatment.  Intestinal  tuberculosis  :  seat 
of  the  disease ;   symptoms  ------     532 


CHAPTER  XXXVni 

ON    HEMOPTYSIS 

Definition.  Causes  classified  :  from  pulmonary  artery  or  its  capil- 
laries ;  from  bronchial  artery  or  capillaries ;  from  the  aorta  or 
one  of  its  great  branches.  Morbid  changes  in  the  vessels  in 
phthisis  which  lead  to  hemoptysis.  Symptoms,  diagnosis,  prog- 
nosis. Recurrent  haemoptysis  :  illustrative  case ;  pathology  of 
this  form  ---------     546 

CHAPTER  XXXIX 

ON    F.\LSE    OR    SPURIOUS    H.^MOPTYSIS 

Definition.     Various  sources  and  causes  of  the  hemorrhage.     Means 

of  distinguishing   spurious  hemoptysis.     Treatment  -  -     557 

CHAPTER  XL 

ON    OTHER   IMPORTANT   COMPLICATIONS    OF   PULMONARY   TUBERCULOSIS 

Tuberculous  meningitis  :  illustrative  cases ;  analysis  of  symptoms ; 
duration  of  the  disease.  Lardaceous  disease  :  table  showing 
frequency  of  its  occurrence  and  the  organs  affected  in  chronic 
pulmonary  tuberculosis ;  symptoms  and  prognosis.  Albumin- 
uria as  a  complication  of  phthisis.     Fistula  -  -  -     563 

CHAPTER  XLI 

THE  DIAGNOSIS  OF  PULMONARY  TUBERCULOSIS 

Physical  diagnosis.  Detection  of  tubercle  bacilli ;  concentration 
methods  of  staining.  X-ray  examination  only  rarely  of  assist- 
ance ;  illustrative  case.  The  tuberculin  tests  :  subcutaneous ; 
cutaneous;  conjunctival.  The  opsonin  test.  Other  specific  tests  : 
complement-fixation,  precipitin,  cobra  venom  and  agglutination 
tests.     Conclusion  ---.-..     ^-j^ 


XVI  CONTENTS 


CHAPTER  XLII 

GENERAL  OBSERVATIONS  ON  THE  PROPHYLAXIS  AND  TREATMENT 
OF  PULMONARY  TUBERCULOSIS 


I'AGE 


General  precautions.     General  observations  on  treatment  :  hygiene  of 

the  sick-room ;  disposal  of  sputum  ;  dietary  ;  exercise         -  -     593 


CHAPTER  XLOI 

TREATMENT  OF  PULMONARY  TUBERCULOSIS  IN  ITS  EARLY 
STAGES — SANATORIUM  TREATMENT 

Cases  suitable  for  sanatorium  treatment.  The  daily  routine  as  exem- 
plified at  the  King  Edward  VII.  Sanatorium.  Exercise  and 
work ;  graduated  labour ;  absolute  rest ;  scientific  observations 
pointing  to  carefully  graded  auto-inoculation  as  the  curative 
factor  in  the  treatment.     The  dietary.     Medicinal  treatment       -    606 


CHAPTER  XLIV 

TREATMENT   OF    PULMONARY   TUBERCULOSIS   IN    ITS    EARLY    STAGES 

(continued) — results   of   sanatorium   treatment 

Results  of  sanatorium  treatment  among  the  industrial  classes  :  com- 
parison of  results  in  early  and  advanced  cases ;  the  importance  of 
efficient  after-care ;  hints  in  regard  to  change  of  work  and  en- 
vironment ;  the  value  of  the  treatment  among  the  working  classes. 

Results  of  sanatorium  treatment  among  the  wealthier  classes  :  records 
from  the  Adirondack  Cottage  Sanitarium  and  the  King 
Edward  VII.  Sanatorium,  Midhurst;  detailed  results  from  the 
latter  institution ;  diagrams  illustrating  hopeful  outlook  among 
early  cases  of  this  group. 

Illustrative  cases  showing  lasting  arrest  obtained  from  hygienic  treat- 
ment among  well-to-do  patients  not  carried  out  in  a  sanatorium     619 


CHAPTER  XLV 

on    CLIMATIC    CHANGE    IN    THE    TREATMENT    OF    PULMONARY 

tuberculosis 

The  effect  of  recent  legislative  enactments  in  restricting  this  method 
of  treatment. 

Climatic  resorts.  Elevated  climates  :  remedial  properties  of  these 
climates  in  pulmonary  and  surgical  tuberculosis.  Heliotherapy. 
Cases  suitable  for  treatment.  The  Alpine  stations ;  the  Rocky 
Mountains  of  North  America;  the  South  American  Andes;  the 
South  African  Highlands ;  La  Cumbre  district  of  the  Argentine ; 
the  hiU-stations  of  India.  Stations  of  medium  elevation.  Table 
giving  climatological  data  relating  to  different  health-resorts       -     636 


CONTENTS  XVll 


CHAPTER  XLVI 


ON    CLIMATIC    CHANGE    IN    THE    TREATMENT    OF    PULMONARY 

TUBERCULOSIS   (continued) 


PAGE 


Marine,  maritime,  and  inland  climates.  Autumn  resorts.  Sea 
voyages.  Winter  resorts  :  English  stations ;  the  Riviera,  Western 
and  Eastern;  Algiers;  Egypt;  Madeira;  the  Canary  Isles.  Cali- 
fornia. Spring  stations.  Summer.  Localities  near  London 
suitable  for  permanent  residence  .  -  -  -  .    653 


CHAPTER  XLVn 

TREATMENT    OF    PULMONARY    TUBERCULOSIS    (continued) 

Acute  first-stage  cases  :  general  plan  of  treatment.  The  uses  and  ad- 
ministration of  cod-liver  oil.  Period  of  active  softening  and 
formation  of  cavities;  treatment  of  pyrexia,  cough  and  night- 
sweating.  Question  of  artificial  pneumothorax.  General  sum- 
mary -  -  -  -  -  »  -  -  -     671 

• 

CHAPTER  XLVni 

TREATMENT  OF   PUL.MONARY  TUBERCULOSIS    (continued) 

The  more  quiescent  period  :  the  use  of  creosote  and  guaiacol. 
Quiescent,  secreting,  and  ulcerous  cavities.  The  management  of 
the  chronic  and  fibroid  stages  ------     687 

CHAPTER  XLIX 

TREATMENT     OF     THE     COMPLICATIONS     OF     PULMONARY     TUBERCULOSIS 

Ulceration  of  the  bowel  :  acute  and  chronic  stages.  Laryngeal  tuber- 
culosis. Aphthous  mouth  and  throat.  Effect  of  pregnancy  and 
lactation.  Haemoptysis:  primary  and  intercurrent;  recurrent; 
spurious.  Vomiting  with  cough.  Intercurrent  pleurisy.  Tuber- 
culous   meningitis  .......     694 

CHAPTER  L 

SPECIFIC    TREATMENT    OF    PULMONARY    TUBERCULOSIS 

General  review  of  vaccine  therapeutics.  Treatment  with  tuberculin  : 
varieties  of  tuberculin ;  dosage ;  cases  suitable  for  treatment ;  im- 
mediate and  subsequent  results  of  treatment,  as  exemplified  in 
the  records  of  the  King  Edward  VII.  Sanatorium,  Midhurst. 
Conclusions  in  regard  to  the  value  of  tuberculin.  Serum-therapy. 
Specific  treatment  of  mixed  and  secondary  infections         -  -     711 


XVlll  CONTENTS 


CHAPTER  LI 


THE    TREATMENT    OF    PULMONARY    TUBERCULOSIS    BY 
(l)   ARTIFICIAL   pneumothorax;    (2)    SURGICAL   INTERVENTION 


PAGE 


Artificial  Pneumothorax  :  description  of  method ;  technique ;  possi- 
bilities of  pleural  reflex  and  gas  embolism ;  duration  of  treat- 
ment. Complications  :  pleurisy ;  perforation  of  lung  and  pleura, 
with  illustrative  case.  Patients  suitable  for  treatment.  Results  of 
treatment. 

Surgical  intervention  :  thoracoplasty ;  rib-mobilisation ;  opening  and 

drainage  of  tuberculous  cavities  -  -  -  -  -     719 

CHAPTER  LH 

TREATMENT    OF    PULMONARY    TUBERCULOSIS    {coiicluded) 
Summary  of  conclusions       -_--.-.     732 

CHAPTER  LHI 

ON    ABSCESS    IN    THE    MEDIASTINUM 

Causes;  symptoms;  diagnosis  and  treatment.     Chronic  mediastinitis 

and  indurative  mediastino-pericarditis  .  .  -  -     734 

CHAPTER  LIV 

INTRATHORACIC  TUMOURS 

Tumours  of  the  mediastinum  :  varieties ;  relative  frequency  of  inno- 
cent and  malignant  forms.  The  sarcomatous  growth  :  seat  of 
origin;  morbid  appearances;  symptoms  and  physical  signs; 
illustrative  cases;  diagnosis,  course,  and  treatment.  Tumours  of 
the  lungs  :  primary  and  secondary       -----     j^y 

Index    ----------     7154 


LIST   OF    PLATES 

PLATE  I'AGE 

I.  X-Ray   Photograph,   showing   the   Normal   Distribu- 
tion   and    General    Arrangement    of    the    Bronchial 
Tree  -  -  -  -  -  -  -to  face        2 

II.  Curschmann's   Spirals      -  -  -  -  -  ,,  74 

III.  Acute     Serous     Pleurisy,     complicating     Pulmonary 

Tuberculosis  -  -  -  -  -  -  ,,  108 

IV.  Pneumothora.^f,    showing    Small    Point    of    Rupture 

in   Pleura  -  -  -  -  -  -  ,,  136 

V.  Pneumothorax,  showing  Two  Large  Perforations  of 

the  Pleura  -  -  -  -  -  -  „  138 

VI.  X-Ray  Photograph  of  a  Case  of  Pyo-pneumothorax  -  ,,  147 

VII.  X-Ray  Photograph  of  a  Case  of  Pyo-pneumothorax 

Subphrenicus        -  -  -  -  -  -  ,,  149 

VIII.   Casts  Expectorated  in  Plastic   Bronchitis       -  -  ,,  196 

IX.  Cylindrical   Bronchiectasis  -  -       ■     -  -  ,,  206 

X.   Saccular    Bronchiectasis  -  -  -  -  -  ,,  207 

XI.  Acute   Bronchiolectasis    -  -  -  -  -  ,,  211 

XII.  X-Ray  Photograph,  showing  Bon}^  Changes  in  Pul- 
monary   Osteo-Arthropathy        -  -  -  -  ,,  213 

XIII.  Foreign   Body   in   Bronchus       -  -.  -  -  ,,  231 

XIV.  Sputum    from    a    Case    of    Asthma,    showing    many 

Bronchial   Casts  -  -  -  -  -  ;,  266 

XV.  Interstitial  Emphysema  -  -  -  -  -  ,,  284 

XVI.  Pneumokoniosis     -  -  -  -  -  ■  ,;  338 

XVII.  Pneumokoniosis   (Silicosis)   complicated  by  Tubercle  ,,  340 

XVIII.  X-Ray  Photograph  of  a  Case  of  Gold-Miner's  Phthisis  .,  342 

XIX.  Radiogram  of  a  Case  of  Massive  Collapse  of  the  Lung  .,  349 

XX.  X-Ray  Photograph  of  a  Case  of  Hydatid  of  the  Lung  ,,  369 

XXI.  Hydatid   of   the  Lung     -  -      .      -  -  -  ,,  376 

xix 


PAG 

-  to  face 
1 

38 

51 

39 

)               ,, 

40 

5  5 

40 

)         „ 

42 

XX  LIST   OF    PLATES 

I'LATE 

XXIL  Congenital   Syphilitic   Pneumonia 

XXIII.  Streptothrix     Organisms     from     Pus     and     Sputum 

{coloured)  .  .  .  -  . 

XXIV.  Streptothrix  Disease  of  Lung  and  Pleura  {coloured) 
XXV.  Streptotrichosis  of  Lung 

XXVI.  Tubercle  Bacilli  in  Sputum  and  Cavities  {coloured) 
XXVII.  Tubercle  Bacilli  in  Acute  Miliary  Tuberculosis  and 

in  Pus  from  a  Tuberculous  Empyema  {coloured)     -       ,,  42 

XXVIII.  The  CEdematous   Pleura — a   Stage  in   the  formation 

of  the  Thickened  Pleura  {coloured)    -  -  -  frontisfiec 

XXIX.  Arrested  Tuberculosis  of  Lung  -  -  -to  face    50 

XXX.  Arrested     Tuberculosis     with    Total    Excavation    of 

Lung  -  -  -  -  -  -  -       ,.  52: 

XXXI.  Ruptured  Pulnionary  Aneurism  in  a  Chronic  Cavity       ,,  54! 

XXXII.  Pulmonary  Aneurism  associated  with  Recent  Tuber- 
culous Disease     -  -  -  -  -  ■       "  55' 

XXXIII.  Apparatus  for  Performing  Artificial  Pneumothorax       ,,  ■/21 

XXXIV.  Sarcoma  of  Mediastinum  invading  the  Lung  -       ,,  73I 
XXXV.  Cells  from  a  Case  of  Pleural  Effusion  of  Malignant 

Origin  {coloured)  -  -  -  -  -       ,,  74; 

XXXVI.   Secondary   Chondro-Carcinoma  of   Lung         -  -       ,,  75: 


In  addition  to  the  above  plates  the  volume  is  illustrated  with  numerou; 
Figures  and  Diagrams  in  the  text. 


DISEASES   OF 
THE   LUNGS  AND    PLEURAE 


CHAPTER  I 

ON  SOME  ESSENTIAL  POINTS   IN  THE  ANATOMY  AND 
FUNCTIONS  OF  THE  LUNGS 

It  would  seem  a  necessary  preliminary  to  a  discussion  of  the 
pathology,  detection  and  treatment  of  chest  diseases  to  recall 
to  the  recollection  of  the  reader  some  of  the  more  essential 
points  respecting  the  anatomy  and  function  of  the  lungs  which 
he  may  have  in  part  forgotten.  Both  physiology  and  anatomy, 
learned  in  the  earlier  stages  of  the  student's  curriculum,  must 
be  relearned  as  he  advances  to  practical  medicine,  and  oft 
reverted  to  in  after  years;  and  it  is  further  true,  as  Addison 
asserted,  that  morbid  anatomy  and  pathology  need  to  be  more 
nearly  regarded  as  reflecting  light  upon  the  structure  and 
functions  of  healthy  organs.  In  the  physiological  laboratory 
we  read  life  forwards,  in  the  post-mortem  room  backwards; 
and  in  the  latter  we  may  perceive  those  instructive  extensions 
and  compensatory  developments  of  healthy  structure  and  func- 
tion which  have,  perhaps,  for  long  maintained  the  vital  balance 
in  otherwise  hopeless  cases.     . 

It  is  impossible  truly  to  comprehend  the  manifold  incidents 
and  conditions  of  such  diseases  as  asthma,  emphysema,  pleu- 
ritic effusion,  pneumothorax  and  many  other  chest  maladies, 
without  a  working  knowledge  of  those  statical  and  dynamical 
conditions  of  respiration  in  health,  to  a  consideration  of  which 
we  will  now  without  further  apology  proceed. 

Anatomy. — The  average  weight  of  the  lungs  in  the  male 
may  be  taken  as  24  ounces  for  the  right,  22  ounces  for  the  left ; 
in  the  female  about  5  ounces  less  in  each  case. 


2  DISEASES   OF   THE   LUNGS   AND   PLEURA 

Perhaps  one  could  not  better  summarise  the  rough  anatomy 
of  the  lung  than  by  quoting  the  first  four  aphorisms  of 
Addison'  respecting  it.  These  affirm:  (i)  "That  the  aerial 
cellular  tissue  of  the  lungs  is  made  up  of  well-defined  rounded 
or  oval  lobules,  united  to  each  other  by  interlobular  cellular 
membrane,  each  lobule  constituting  a  sort  of  distinct  lung  in 
miniature,  having  its  own  separate  artery  and  vein;  (2)  that 
these  lobules  do  not  communicate  directly  with  each  other; 
(3)  that  they  do  not  consist  of  the  globular  extremities  of  as 
many  bronchial  tubes,  but  are  made  up  of  a  collection  of  cells 
in  which,  by  a  common  opening,  a  minute  filiform  bronchial 
tube  abruptly  terminates;  (4)  that  the  pulmonary  artery 
accompanies  the  bronchi,  branch  for  branch,  to  the  minutest 
divisions  of  the  latter." 

The  general  arrangement  of  the  bronchi  is  shown  in  the 
accompanying  radiograph  from  Dr.  Brunings'-  work  (Plate  I.). 

If  we  trace  the  bronchial  tubes  from  the  trachea  into  the 
depth  of  the  lungs,  we  find  that  they  divide  in  a  peculiar 
manner:  (i)  from  the  main  bronchi  down  to  a  calibre  of 
^  inch  (4  mm.)  they  divide  symmetrically  or  dichotomously; 
(2)  beyond  ^  inch  the  bronchi  proceed  in  straight  lines, 
gradually  diminishing  in  size  and  giving  off  lateral  branches 
alternately  at  an  angle  of  about  45°;  (3)  these  lateral  branches 
again  divide  dichotomously  until  they  reach  a  diameter  of 
about  y^o  inch  (o'25  mm.),  soon  after  which  they  terminate  in 
several  alveolar  passages  or  atria,  which,  with  the  infundibula 
and  air  cells  attached,  form  the  lobules  referred  to  by  Addison. 
The  mode  of  termination  of  the  bronchioles  is  illustrated  in 
the  diagram  of  the  lung  lobule  (Fig.  i),  constructed  by 
Professor  W.  F.  Miller.^  Whilst  in  general  the  branchlets  of 
the  bronchial  tree  have  their  direction  onwards,  some,  accord- 
ing to  Dr.  Ewart,^''  may  be  found  to  take  a  backward  or  re- 
current direction  to  their  termination  in  the  pulmonary  lobules. 
A  distinct  tendency  may  be  observed  throughout  the  bronchial 
system  for  each  bifurcation  to  occur  in  a  plane  perpendicular 
to  that  of  the  preceding  bifurcation,  alternate  bifurcations 
thus  taking  place  in  the  same  plane.** 

Down  to  a  diameter  of  -^^  inch  (i  mm.)  the  bronchial  divi- 
sions are  possessed  of  cartilages  and  muscular  coat,  are  lined 
by  a  ciliated  epithelium,  and  are  furnished  with  mucous  glands. 
Their  arterial  supply  is  thus  far  derived  from  the  bronchial 


PLATE  I 


X-RAY  PHOTOGRAPH,  TAKEN  FROM  BEHIND,  SHOW- 
ING THE  NORMAL  DISTRIBUTION  AND  ARRANGE- 
MENT OF  THE  BRONCHIAL  TREE 

From  a  cadaver  in  which  the  trachea  and  bronchi  had  been 
filled  with  a  solution  of  lead  oxide  and  gelatine. 


PLATE  I 


X-Ray  Photograph,  showing  the  Normal  Distribution  and  General 
Arrangement  of  the  Bronchial  Tree.     (After  Dr.  W.  Brunings.^) 


To  face  p.  2. 


ANATOMY  AND   FUNCTIONS   OF  THE  LUNGS  3 

artery,  the  capillaries  of  which  terminate  in  the  bronchial  veins, 
forming  a  part,  therefore,  of  the  systemic  circulation. 

Below  the  diameter  of  ^\-  inch  the  bronchi  have  neither 
cartilages  nor  mucous  glands,  but  their  muscular  coat  and  the 
elastic  fibres  persist,  and  ciliated  epithelium  lines  the  tube, 
although  soon  to  give  place  to  flattened  non-ciliated  cells. 
The  arterial  supply,  still  derived  from  the  bronchial  artery, 
terminates  in  the  pulmonary  venous  capillaries,  and  forms 
therefore  a  part  of  the  pulmonary  circulation. 


Fig.  I. — Scheme  of  the  Lung  Lobule  of  the  Mammalian  Lung 
(after  Prof.  W.  S.  Miller,  from  Schafer's  "  Essentials  of 
Histology"). 

B,  terminal  bronchiole;  V,  vestibule;  A,  atrium  or  alveolar  passage; 
S,  air-sac  (infundibulum)  ;  C,  air-ceU  (alveolus) ;  P,  ending  of  pul- 
monary arteriole;   T,  commencement  of  pulmonary  venule. 

The  alveoli,  or  little  recesses,  about  you  inch  (0-25  mm.)  in 
diameter,  with  which  the  alveolar  passages  and  infundibula 
are  studded,  are  composed  mainly  of  a  framework  of  fine 
hbrous  tissue,  among  which  numerous  elastic  fibres  are  to  be 
seen.  They  are  lined  internally  by  a  delicate  flattened  epithe- 
lium, and  are  surrounded  externally  by  a  network  of  capillaries. 

Each  lobule  of  the  lung  is  thus  made  up  of  a  lobular  bronchus 
or  bronchiole,  with  the  alveolar  passages,  infundibula  and 
alveoli  connected  with  it.  Adjacent  lobules  are  separated  from 


4  DISEASES   OF  THE  LUNGS   AND  PLEURAE 

each  other  by  bands  of  fibrous  tissue,  forming  the  so-called 
interlobular  septa,  continuous  on  the  one  hand  with  the  sub- 
pleural  fibrous  tissue,  and  on  the  other  hand  with  that  sur- 
rounding the  bronchi  and  bloodvessels,  and  thus  ultimately 
with  the  connective  tissue  of  the  mediastinum.  On  the  surface 
of  the  lung  in  the  adult,  as  may  be  seen  in  the  accompany- 


FiG.  2. — External  Surface  of  the  Right  Lung,  showing  the 
Division  into  Lobules  (after  Poirier  and  Charpy^). 

ing  figure  (Fig.  2),  the  division  between  the  lobules  is  gener- 
ally visible  to  the  naked  eye,  their  boundaries  being  marked 
out  by  a  greater  or  less  deposit  of  carbonaceous  material. 
Their  size  varies,  according  to  the  late  Professor  MacAlister, 
from  I  inch  to  |  inch  (6  mm.  to  10  mm.)  in  diameter. 
With  regard  to  the  bloodvessels  of  the  lungs,  it  should  be 


ANATOMY  AND  FUNCTIONS  OF  THE  LUNGS        5 

borne  in  mind  that  the  pulmonary  artery,  carrying  dark  blood, 
subdivides  with  the  bronchial  tubes,  and  finally  furnishes  a 
capillary  layer  to  each  alveolus,  each  branch  proceeding  to  its 
final  distribution  without  communicating  with  any  other 
branch.  A  junction  between  the  pulmonary  and  systemic 
vessels  is,  however,  affected  at  the  pulmonary  lobules  by  the 
discharge  of  the  capillaries  of  the  bronchial  artery  into  those 
of  the  pulmonary  vein  as  aforesaid.  The  veins  have  no  valves, 
and  for  the  most  part  take  a  separate  course  to  the  root  of 
the  lung  in  the  interlobular  or  pulmonary  fissures.  They 
anastomose  freely. 

Respiratory  Function  and  Mechanism. — In  the  recesses  of 
the  lungs  within  the  alveoli  and  alveolar  passages  is  effected 
that  interchange  of  gases  by  means  of  which  oxygen  is  on 
the  one  hand  absorbed,  and  carbon  dioxide  (CO^)  exhaled, 
although  the  minutest  bronchi  also  allow  of  a  certain  oxygena- 
tion of  blood  through  their  fine  membrane.  The  laws  under 
which  this  interchange  is  carried  on  are  in  the  main  those 
which  regulate  the  diffusion  of  gases  and  their  passage 
through  moist  membranes,  though  it  is  possible,  as  urged  by 
Douglas  and  Haldane''  and  others,  that  when  the  need  of 
oxygen  is  great,  a  direct  secretory  activity  of  the  alveolar  cells 
is  brought  into  action,  whereby  oxygen  is  taken  up  by  them 
and  excreted  into  the  blood  of  the  pulmonary  capillaries.  The 
interchang'e  of  gases  thus  brought  about  is,  so  to  speak,  the 
basis  of  the  respiratory  function;  but  in  order  that  this  func- 
tion may  go  on  uninterruptedly,  it  is  obvious  that  special 
provisions  must  be  made  for  a  regulated  renewal  of  the  blood 
operated  upon  and  a  thorough  and  sustained  ventilation  of 
the  minute  air  chambers  in  which  the  process  takes  place. 
The  rhythmic  contractions  of  the  right  ventricle  of  the  heart 
insure  a  continuous  current  of  blood  through  the  alveolar 
capillaries,  and  the  rhythmic  respiratory  movements  secure, 
under  conditions  to  be  immediately  stated,  a  thorough  ventila- 
tion of  the  lungs. 

Let  us  now  glance  at  the  mechanism  by  which  these  respira- 
tory movements  are  effected.  If  a  small  portion  of  the 
medulla — an  area  the  limits  of  which  have  not  been  very 
clearly  defined,  but  which  may  be  described  as  lying  below  the 
vaso-motor  centre  in  the  immediate  neighbourhood  of  the 
nuclei  of  the  vagus  nerves — be  removed  or  injured,  respiration 


6  DISEASES   OF  THE  LUNGS   AND   PLEURA 

ceases,  and  death  at  once  ensues.  This  portion  of  the  nervous 
system  was  named  by  Fleurens  the  nceud  vita],  or  gangHon 
of  life.  It  is  generally  spoken  of  as  the  respiratory  centre. 
The  action  of  the  centre  in  starting  and  regulating  the  respira- 
tory function  is  partly  automatic,  partly  the  result  of  reflex 
stimulation.  It  is  automatic  in  the  sense  that  the  fundamental 
respiratory  impulses  are  generated  in  the  centre  itself  as  a 
result  of  the  stimulating  influence  of  increasing  quantities  of 
carbonic  acid  in  the  circulating  blood;  but  reflex  in  that  it  is 
most  delicately  responsive  to  peripheral  stimuli  reaching  it 
from  diverse  quarters. 

It  need  scarcely  be  observed  that  in  the  foetus  at  the  full 
term  the  lungs  are  in  a  state  of  complete  and  airless  collapse, 
that  the  diaphragm  is  in  a  position  of  extreme  convexity  up- 
wards, and  the  thorax  in  the  position  of  utmost  contraction, 
the  respiratory  function  being  effected  by  the  interchange  of 
gases  between  the  foetal  villi  of  the  placenta  and  the  maternal 
blood  in  which  they  are  steeped. 

In  the  new-born  child,  however,  on  the  placental  circulation 
being  interrupted,  carbon  dioxide  accumulates  in  the  blood 
and  stimulates  the  respiratory  nervous  centres,  thus  exciting 
acts  of  inspiration.  This  central  nervous  stimulation  would 
probably  not  alone  be  sufficient,  but  it  is  supplemented,  on  the 
first  exposure  of  the  child  to  the  external  air,  by  a  general 
excitation  of  the  cutaneous  nerves,  causing  strong  inspiratory 
movements.  Doubtless  also  the  opening  out  of  the  air  cells  is 
further  facilitated  by  a  kind  of  erectile  influence  produced  by 
the  injection  of  their  capillaries  with  blood,  a  view  originally 
suggested  by  Dr.  Philip  Hensley/  in  his  Goulstonian  Lectures 
for  1872,  and  supported  later  by  the  experiments  of  Lieber- 
mann.^  As  the  result  of  these  combined  forces,  air  penetrates 
the  lungs,  and  is  never  again  fully  expelled. 

It  is  not  at  all  curious  that  the  lungs,  thus  once  inflated, 
should  remain  more  or  less  permanently  expanded,  retaining 
in  their  interior  a  certain  amount  of  air.  They,  like  any 
ordinary  elastic  air  bags,  would  do  this,  whether  in  or  out  of 
the  body.  But  in  the  body,  both  during  life  (within  the 
limits  of  ordinary  respiration)  and  after  death,  the  lungs  are 
maintained  at  a  degree  of  expansion  greater  than  that  to 
which  they  would,  by  their  mere  elasticity,  revert.  This  is 
a  fact  admitted  by  modern  physiologists,  but  its  importance 


ANATOMY  AND  FUNCTIONS  OF  THE  LUNGS        7 

in  clinical  medicine  is  perhaps  not  yet  sufficiently  recognised. 
In  order  to  account  for  the  maintenance  of  the  lung  in  this 
semi-expanded  state,  we  must  assume  that  when  the  muscles 
of  respiration,  which  are  for  the  most  part  inspiratory  muscles, 
have  once  been  excited  to  action,  they  remain  permanently 
shortened  by  virtue  of  their  vital  contractility  or  tonus.  And 
in  the  rapid  course  of  tissue  growth  the  ribs  and  cartilages 
become  moulded  to  that  wider  arc  which  they  have  thus  been 
brought  to  assume. 

The  residual  tension  or  pressure  depending  upon  the  elas- 
ticity of  the  lungs  has  been  measured  by  different  observers 
with  somewhat  different  results.  Dr.  Carson,®  who  in  1820 
was  the  first  to  demonstrate  the  existence  of  this  reserve 
tension,  estimated  it  in  different  animals  as  equivalent  to  from 
6  to  20,  or  more,  inches  of  water,  according  to  the  size  of  the 
animal.  He  fully  perceived  the  importance  of  this  elastic 
force,  both  in  the  respiratory  mechanism  and  as  an  aid  to  the 
circulation,  though  he  misinterpreted  its  effects. 

Bonders,^"  in  1853,  niade  some  experiments  on  the  human 
subject.  By  connecting  a  manometer  with  the  trachea,  and 
then  carefully  opening  the  thorax,  he  was  able  to  ascertain  the 
residual  elastic  tension  of  the  lungs,  and  concluded  that  in  the 
healthy  person  it  was  equal  to  80  mm.  (about  3  inches)  of 
water.  He  further  allowed  20  mm.  for  the  tonicity  of  con- 
tractile elements  in  the  lung,  making  thus  during  life  a  total 
pressure  or  traction  of  100  mm.  of  water  or  7' 5  mm.  of 
mercury. 

Dr.  Salter,  in  1865,"  found  the  residual  tension  in  the  dog 
equal  to  4  inches  of  water. 

Dr.  M.  Perls,'^  in  1869,  gave  the  result  of  100  experiments, 
conducted  in  the  same  manner  as  those  of  Donders,  upon 
persons  who  had  died  of  different  diseases  :  out  of  these,  in 
twenty-five  cases  death  had  been  caused  by  diseases  remote 
from  the  lungs,  although  in  most  instances  the  lungs  were  in 
some  degree  affected.  The  highest  residual  tension  registered 
by  Dr.  Perls'  manometer  from  these  twenty-five  cases  was 
60  mm.  of  water;  the  lowest,  5  mm.;  mean,  35-3  mm.  It  is 
probable  that  the  experiments  of  this  observer  give  results 
somewhat  short  of  those  of  perfect  health.  It  is,  at  all  events, 
noteworthy  that  the  highest  elastic  pressure  obtained  by  him 
in  the  twenty-five  cases  in  which  the  lungs  were  presumably 


.8  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

healthy  did  not  equal  that  (63  mm.)  obtained  from  cases  of 
bronchitis  and  phthisis  respectively.  The  subject  has  not 
attracted  much  attention  in  recent  years,  but,  pending  further 
inquiry,  we  shall  probably  not  be  far  wrong  if  we  take  a  mean 
of  the  figures  observed  by  Hutchinson  and  Aron"  and  those 
of  Bonders,  and  accept  5  mm.  of  mercury  as  a  fairly  accurate 
estimate  of  the  pressure  or  traction  exerted  by  the  elasticity 
of  the  lungs  in  the  expiratory  position,  and  7  mm.  for  that 
exerted  at  the  end  of  a  normal  inspiration.  At  the  end  of 
very  deep  inspiration  the  pressure  may  rise  as  high  as  30  mm. 
(Bonders)." 

The  amount  of  muscular  tissue  in  the  human  lung  is  at  most 
but  scanty.  Some  authors,  indeed,  deny  its  existence,  though 
in  animals,  such  as  the  dog,  it  is  certainly  present,  as  proved 
by  the  contraction  exhibited  by  the  lungs  of  this  animal  when 
brought  in  contact  with  ice-cold  water  (Miiller).^*  In  the 
human  subject,  however,  we  may  conclude  that,  so  far  as  the 
lung  proper  is  concerned,  muscular  action  takes  no  direct  part 
in  the  respiratory  mechanism.  The  bronchioles,  however, 
which  are  in  intimate  union  with  the  texture  of  the  lungs,  are 
provided  with  unstriated  muscular  fibres  innervated  by  motor 
nerves  from  the  vagi.  Stimulation  of  these  nerves  causes  con- 
traction of  the  bronchioles.  Dr.  Watson  Williams^"  holds  the 
view  that  the  bronchioles  normally  expand  and  contract 
rhythmically,  especially  in  children,  the  expiratory  contraction 
being  in  comparative  abeyance  during  quiet  breathing  in 
adults,  and  that  in  asthma  the  contractive  phase  of  physio- 
logical respiration  is  merely  exaggerated.  He  bases  his  view 
upon  the  acceptation  by  physiologists  of  afferent  and  efferent 
fibres  to  the  bronchi  in  the  pneumogastric  nerve  connected 
with  the  respiratory  centre,  and  upon  the  fact  that  the  larynx 
has  rhythmic  movements  corresponding  with  those  of  respira- 
tion, which  movements  are,  in  very  young  children,  shared  by 
the  alae  nasi. 

Whilst  the  residual  tension  of  the  lungs  has  been  thus  care- 
fully tested  and  measured,  the  corresponding  thoracic  tension 
necessarily  equal  and  opposite  to  it  has  almost  escaped  obser- 
vation ;  indeed,  it  has  been  deliberately  misplaced  and  regarded 
as  an  expiratory  force. 

It  was  maintained  by  John  Hutchinson,"  Assistant  Physician 
to  the  Brompton  Hospital,  in  an  able  and  elaborate  paper  read 


ANATOMY   AND   FUNCTIONS    OF   THE   LUNGS  9 

before  the  Royal  Medical  and  Chirurgical  Society  of  London, 
that  inspiration  is  a  zvholly  muscular  act,  the  muscles  in  ex- 
panding the  thorax  having  to  contend  against  (i)  the  elastic 
resistance  of  the  lungs;  (2)  the  inertia  and  elastic  resistance  of 
the  chest  walls.  Expiration,  on  the  other  hand,  he  believed  to 
be  effected  by  the  elastic  recoil  of  the  lungs  and  chest  walls; 
and  this  theory  of  the  mechanism  of  healthy  breathing  long 
found  favour.  The  view  cannot,  how^ever,  be  accepted  with- 
out some  modification.  The  recent  work  of  Dr.  Arthur 
Keith,''  Professor  Sherrington,  and  others,  suggests  that 
normal  expiration  should  not  be  regarded  as  entirely  the 
result  of  elastic  recoil,  but  that  the  muscles  of  the  abdominal 
wall  regularly  take  some  share  in  the  performance  of  the  act. 

In  regard  to  inspiration  also  the  view  embodies  a  fallacy. 
Thus  it  is  incorrect  to  state  that  in  quiet  inspiration  the 
muscles  of  the  thorax  have  to  contend  against  the  inertia  and 
elastic  resistance  of  the  chest  walls,  as  well  as  that  of  the 
lungs.  Far  from  this  being  the  case,  the  thoracic  elasticity  is 
a  reserve  force  of  appreciable  power  constantly  tending  to 
enlarge  the  chest,  and  acts,  therefore,  during  quiet  breathing, 
in  favour  of  inspiration.  That  this  must  be  so  would  appear 
to  follow,  as  a  matter  of  reasoning,  from  what  has  been 
observed  above  respecting  the  state  of  tension  in  which  the 
lungs  are  maintained,  so  long  as  they  remain  healthy,  through- 
out life;  but  more  fully  to  demonstrate  the  proposition,  a 
brief  reference  may  be  made  to  some  observations  and  experi- 
ments which  bear  upon  the  subject. 

The  late  Dr.  Salter^'  was  the  first  to  point  out  that  at  the 
commencement  of  breathing  the  elasticity  of  the  chest  walls 
should  be  placed  as  an  inspiratory  force.  By  a  simple  experi- 
ment he  showed  that  in  the  dead  subject,  the  thorax,  when 
relieved  from  the  traction  of  the  lungs  by  an  opening  made 
into  the  pleura,  expanded  to  the  extent  of  y^^  inch.  Paul 
Bert'^  (1870),  in  some  ingenious  experiments,  recorded  simul- 
taneously the  elastic  pressure  of  the  lungs  and  the  expansion 
of  the  chest  wall  at  the  moment  of  opening  the  pleura  of  a 
recently  killed  dog.  Traube,'°  in  1871,  found  that  in  the  living 
dog  the  chest  walls,  on  being  relieved  from  the  traction  of  the 
lungs,  expanded  in  the  manner  indicated  by  Salter;  but 
Traube  does  not  seem  to  have  been  aware  either  of  Salter's  or 
of  Bert's  experiments,  and  he  erroneously  asserts  that  the 


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ANATOMY   AND   FUNCTIONS   OF   THE   LUNGS 


II 


expansion,  which   he   attributes   to   muscular   action,   is   not 
obtained  in  the  dead  animal. 

The  appended  table  contains  the  details  of  ten  post-mortem 
examinations  made  by  one  of  us  to  estimate  the  extent  to 
which  the  chest  wall  would  expand  of  its  own  resilience 
when  relieved  from  the  traction  of  the  lungs.'""  The  difficulty 
of  finding  the  thoracic  organs  perfectly  healthy  in  the  dead 
subject  is  well  known,  and  out  of  the  ten 
cases  operated  upon,  in  only  four  instances 
were  they  approximately  so.*  The  experi- 
ments were  performed  after  the  manner  of 
Salter  by  taking  a  fine  tube,  A  (Fig.  3),  ex- 
panded below  and  having  stretched  across 
its  expanded  extremity,  B,  a  piece  of  caout- 
chouc provided  with  a  projecting  button,  C. 
The  instrument,  having  been  filled  with  col- 
oured fluid,  was  so  adjusted  that  the  button 
was  accurately  applied  to  the  third  cartilage, 
the  integuments  having  been  previously 
reflected  from  the  front  of  the  chest.  The 
level  of  the  fluid  having  been  noted  on  the 
Scale  D  attached  to  the  stem,  the  thorax  was 
cautiously  opened,  and  an  immediate  rise  of 
the  coloured  fluid  was  observed.  A  simple 
calculation  enabled  one  to  ascertain  the 
actual  expansion  registered.  The  results  of 
the  experiments  will  be  seen  in  the  table ;  in 
the  four  comparatively  healthy  cases  the 
expansions  (forward  movement)  measured 
were  1-63  mm.,  2-143  nim.,  239  mm.,  and 
3-19  mm.  respectively.  These  figures,  small 
though  they  are,  correspond  pretty  well  with 
the  limits  of  expansion  of  the  ribs  during  calm  breathing. 
Thus  Hutchinson  calculated  the  costal  movement  in  health 
at  xV  to  I  line  =  I  to  2  mm.;  Sanderson  gives  i"6  mm.  Our 
own  measurements,  nineteen  in  number,  recorded  in  the  paper 
above  referred   to,'"*    by   an   instrument   with   writing   lever, 

*  Professor  Keith,  in  his  reference  to  these  experiments,  omits  to  note 
that  only  in  these  four  cases  were  the  lungs  approximately  healthy,  their 
action  in  the  other  cases  being  impaired  by  oedema,  emphysema  or  pleuritic 
effusion. 


Fig.  3.  —  Instru- 
ment FOR  ESTI- 
MATING Expan- 
sion OF  THE 
Chest  Wall 


12 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


would  give  rather  a  higher  figure — viz.,  2  to  3  mm.  It  would 
appear,  then — and  this  is  the  point  to  which  we  wish  especially 
to  direct  attention  —  that  in  health,  throughout  ordinary 
inspiration,  the  limit  of  thoracic  recoil,  which  we  may  call  the 
reserve  capacity  of  the  thorax,  is  barely  reached;  and,  there- 
fore, that  the  sole  resistance  to  he  overcome  by  the  inspiratory 
muscles  is  that  of  the  lungs. 

This  elastic  help  at  the  beginning  and  hindrance  at  the  com- 
pletion of  the  respiratory  act  is  a  spring-hke  function  of  the 
chest  wall,  the  importance  of  which  has  not  been  duly 
recognised. 


1^- 


fc? 


t 

H 


Fig.  4. — Diagram  Model  of  the  Chest. 


In  order  more  clearly  to  show  the  main  physical  conditions 
present  in  the  chest,  and  how  they  are  modified,  (a)  during 
normal  respiratory  movements,  and  (&)  in  certain  diseases, 
the  above  schema  or  diagram-model  of  the  chest  was  designed 

(Fig-  4). 

The  schema  consists  of  a  cylinder  of  glass,  closed  at  each 

end  by  a  metal  plate  screwed  on  and  perforated  for  the  admis- 
sion of  certain  tubes.  A  central  partition,  EF,  made  of  sheet 
india-rubber,  divides  the  cylinder  into  two  air-tight  compart- 
ments, each  of  which,  as  will  be  presently  seen,  represents 
one-half  of  the  thorax. 


ANATOMY   AND   FUNCTIONS    OF   THE   LUNGS  1 3 

Tube  D  represents  the  trachea,  and  is  connected  with  an 
elastic  bag  (c),  representing  the  (left)  lung.  Tube  G  com- 
municates with  the  space  between  the  lung  and  the  wall  of 
the  chamber,  which  space,  therefore,  corresponds  to  the 
pleural  cavity.  This  tube  is  connected  with  a  mercurial 
manometer,  the  free  end  of  which,  L,  is  open  to  the  normal 
atmospheric  pressure.  Tube  B  also  communicates  with  the 
same  (pleural)  space,  and  is  provided  with  a  stopcock  and  a 
mouthpiece. 

Exactly  the  same  parts  are  repeated  on  the  opposite  side 
of  the  partition,  EF,  which  therefore  represents  the  medias- 
tinum. 

The  apparatus  must  be  ascertained  to  be  thoroughly  air- 
tight. Then,  by  partially  exhausting  the  air  from  chamber  A 
througli  tube  B  (trachea  tubes  D  and  D'  remaining  open),  we 
cause  the  bag  c  to  expand  to  C,  the  mercury  in  the  mano- 
meter, HKI,  to  rise  towards  the  chamber,  and  the  mediasti- 
num, EF,  to  become  convex,  as  indicated  by  the  dotted  line. 
By  closing  the  stopcock  B  we  maintain  all  the  parts  in  this 
position. 

If,  next,  we  repeat  the  same  process  on  the  opposite  side — 
partially  exhausting  chamber  A'  through  B'  until  the  mercury 
r  is  at  the  same  level  as  I,  the  bag  c'  will  expand  to  C,  the 
mediastinum,  EF,  will  again  become  vertical,  and  by  closing 
stopcock  B',  the  parts  will  be  maintained  in  this  position  of 
equilibrium  on  the  two  sides. 

In  the  schema  thus  arranged,  we  have  the  conditions  of  the 
healthy  chest  rudely  but  accurately  imitated.  The  two  cham- 
bers represent  the  two  sides  of  the  chest,  each  containing  a 
semi-expanded  lung,  C,  C,  surrounded  by  a  pleural  cavity, 
A,  A'  (here  greatly  exaggerated,*  the  cavity  being  rather 
potential  than  real  in  the  healthy  chest),  each  cavity  being 
separated  from  that  on  the  opposite  side  by  the  mediastinum 
EF,  which  is  common  to  both  and  equipoised  between  them. 

The  walls  of  the  natural  thorax  are,  however,  as  we  have 
seen,  elastic  or  resilient  in  every  part,  although  much  more 
stiffly  so  than  the  lungs.  We  cannot  exactly  represent  this 
resilience  of  the  thoracic  walls  in  our  schema.     The  only  parts 

*  This  is  unavoidable,  since  the  walls  of  the  schema  are  rigid,  and  if 
the  bags  fitted  accurately,  their  further  expansion  in  inspiration  could  not 
be  represented.     No  fallacy  is  hereby  introduced,  however. 


14  DISEASES   OF  THE  LUNGS   AND   PLEURA 

of  our  apparatus  which  are  at  liberty  to  yield  to  the  excess 
of  external  atmospheric  pressure  over  that  within  the  pleurae 
are  the  small  surfaces  of  mercury  at  H,  H'.  Hence  the  eleva- 
tion of  the  mercury,  HI,  H'T,  towards  the  chamber  on  each 
side,  multiplied  by  the  area  of  apertures  G,  G',  and  divided  by 
that  of  the  whole  surface  of  the  chamber,  would  represent 
in  millimetres  the  amount  of  recession  of  each  portion  of  the 
thorax,  provided  each  portion  were  equally  resilient. 

In  considering  this  subject,  we  must  not  forget  the  dia- 
phragm, which  constitutes  the  floor  of  the  chest,  and  which, 
owing  to  its  resistance  being  weaker,  yields  far  more  than 
any  other  portion  of  the  chest  wall  to  the  traction  of  the 
lungs,  so  that  a  recession  of  an  inch  on  the  part  of  the 
diaphragm  is  equivalent  to  the  recession  of  only  i  or  2  mm. 
on  the  part  of  the  ribs  or  cartilages.  And  yet  it  must  be 
remembered  that  the  diaphragm  is  not  per  se  elastic,  and 
that  the  limits  of  its  actual  tension  are  therefore  very  narrow. 
The  elastic  recoil  of  the  diaphragm,  in  fact,  depends  mainly 
upon  the  spring  of  the  cartilages  to  which  it  is  attached.  It 
is  thus  obvious  that  this  muscular  membrane  must  be  drawn 
upwards  and  held  in  a  state  of  tension  by  the  lungs  during 
the  respiratory  pause,  their  traction  being  in  turn  counter- 
balanced by  the  weight  of  the  abdominal  organs.  Our  mer- 
curial columns,  therefore,  after  all,  very  conveniently  and 
fairly  represent  the  whole  thoracic  resilience  in  a  lump  sum. 

Having  thus,  with  the  aid  of  our  schema,  reviewed  the 
statical  conditions  of  the  chest,  the  dynamics  of  respiration 
may  be  easily  demonstrated. 

In  order  to  imitate  an  inspiration,  aspiration  must  be  made 
simultaneously  through  the  tubes  L  and  L',  thus  representing 
the  contraction  of  the  diaphragm  and  inspiratory  muscles  on 
the  two  sides.  This  can  be  conveniently  done  by  means  of  a 
syringe  attached  to  a  branched  caoutchouc  tube  afifixed  to 
the  extremities  L,  L'  of  the  manometers. 

As  the  mercurial  columns  rise  up  the  limbs  L,  L'  of  the 
manometers,  representing  the  expansion  of  the  thorax,  the 
lungs  C,  C  enlarge  by  the  entry  of  air  through  trachea  tubes 
D  and  D'.  " 

It  will  be  observed  that  during  the  first  part  at  least  of 
inspiration  the  weight  of  the  two  columns  of  mercury,  HI, 
HT,  tells  in  favour  of  the  inspiration.     This  weight  of  mer- 


ANATOMY  AND  FUNCTIONS  OF  THE  LUNGS       1 5 

cury  corresponds,  as  before  said,  to  the  outward  resilience  of 
the  thoracic  walls,  and  counterbalances  the  elastic  traction  of 
the  lungs.  This  is  a  fact,  well  shown  in  the  schema,  and 
which  has  been  already  stated  in  the  proposition,  that  in  health 
the  resilience  of  the  chest  wall  is  in  favour  of  inspiration. 
Moreover,  from  the  observations  on  the  dead  subject  to  which 
we  have  already  referred,  it  would  appear  that  this  elastic  aid 
to  inspiration  obtains  throughout  the  act  in  calm  breathing. 
Respiration  is  thus  rendered  smoother  and  less  laborious, 
elasticity  entering  as  an  important  item  into  the  inspiratory, 
as  it  has  been  long  known  to  do  into  the  expiratory  act. 

The  conditions  present  in  the  chest,  as  shown  by  the  schema, 
must  now  be  further  examined  in  so  far  as  they  affect  heart 
and  circulation. 

The  disposition  to  the  formation  of  a  vacuum  in  the  intra- 
pleural space  A,  equal  to  the  weight  of  the  column  of  mer- 
cury HI,  causes  an  aspiration  towards  that  cavity  which  was 
at  first  shown  by  the  convexity  of  the  mediastinum  EF  (dotted 
line) ;  and,  there  being  a  similar  and  equal  aspiration  towards 
the  pleural  cavity  on  the  opposite  side  of  the  mediastinum,  it 
follows  that  there  is  a  constant  determination  of  blood 
towards  the  cavities  and  walls  of  the  heart — a  hollow  organ 
situated  within  the  mediastinum,  and  communicating  by  a 
system  of  tubes  with  parts  outside  the  thorax  (see  Fig.  5). 
This  central  attraction  is  forcibly  overcome  by  the  muscular 
contraction  of  the  heart,  but  resumes  its  sway  at  the  termina- 
tion of  systole,  aiding  the  return  of  blood  to  the  flaccid  heart 
cavities,  and  encouraging  the  flow  through  the  coronary 
vessels.  This  aspiration  towards  the  heart,  it  must  be  remem- 
bered, is  in  health  a  constant  force,  increased  during  inspira- 
tion, held  in  momentary  subjection  during  the  more  forcible 
muscular  contraction  of  the  heart,  and  not  wholly  extin- 
guished even  at  the  end  of  ordinary  expiration. 

In  the  subjoined  drawing  (Fig.  5),  which  depicts  a  some- 
what more  elaborate  diagram  model  of  the  chest  (but  essen- 
tially corresponding  with  that  illustrated  by  Fig.  4),  the 
mediastinum  is  represented  by  a  double  layer  of  caoutchouc 
enclosing  a  space.  With  this  is  connected  the  manometer, 
D,  which  shows  at  a  glance  the  negative  pressure  to  which 
the  heart  is  constantly  subjected  through  the  traction  of  the 
lungs  from  either  side. 


i6 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


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ANATOMY   AND   FUNCTIONS    OF   THE   LUNGS  1 7 

The  reserve  capacity  of  the  chest  to  which  we  have  referred, 
and  which  leads  it,  under  certain  circumstances  and  within 
certain  limits,  to  enlarge  without  muscular  effort  from  with- 
out or  pressure  from  within,  is  a  most  valuable  safeguard, 
and  serves  in  some  diseases  to  protect  the  lungs  from 
pressure  during  temporary  conditions  of  inflammation  or 
engorgement. 

If,  for  example,  we  look  at  a  case  of  pneumonia,  we  find 
that,  whereas  on  the  healthy  side  the  play  of  the  chest  wall  is 
natural  or  increased,  on  the  other  side  it  is  annulled.  There 
is  no  retreat  with  expiration,  and  inspiration  is  checked  by 
pain.  On  post-mortem  inspection,  we  find  the  fine  granula- 
tions of  lymph  evenly  spread  upon  the  pleural  surfaces,  show- 
ing no  sign  of  pressure.  The  patient  suffers  little  pain,  except 
when  he  coughs  or  attempts  to  draw  a  deep  breath.  In  fact, 
as  the  inflamed  and  consolidating  lung  increases  in  bulk,  the 
thoracic  wall,  thereby  released  from  its  elastic-  traction, 
retreats  to  the  position  of  inspiration;  and  this  reserve 
capacity  of  the  thorax  is  rarely  exhausted  in  pneumonia,  so 
that  the  swollen  and  tender  lung  as  a  rule  escapes  com- 
pression. 

Similarly,  in  temporary  engorgement  and  oedema  of  the 
lungs  the  consequences  would  be  much  more  serious  were  it 
not  for  this  reserve  capacity  of  the  thorax,  which  protects 
the  organs  from  compression,  save  in  extreme  cases.  In 
emphysema  the  lungs  are  rarely  enlarged  so  as  to  be  com- 
pressed by  the  ribs,  the  thoracic  resilience  being  entirely 
neutralised  only  in  very  extreme  cases. 

With  regard  to  emphysema,  sl  diminution  of  the  elastic 
spring  of  the  chest  wall  is  one  of  the  first  important  features 
of  the  disease.  In  the  normal  chest,  a  deep  breath  is  drawn 
by  first  making  a  deep  expiration  and  then  a  deep  inspiration. 
In  emphysema  the  power  of  making  a  deep  expiration  is  par- 
tially or  entirely  lost;  the  resei-ve  capacity  of  the  thorax  is 
taken  up,  and  it  is  in  this  direction  that  the  trouble  of  em- 
physematous people  Hes.  Regarding  emphysema  as  in  many 
cases  essentially  a  disease  of  a  degenerative  kind,  we  must 
observe  in  the  constant  traction  of  the  thorax  upon  the 
lungs  a  determining  cause  of  their  enlargement,  as  the 
chest  gradually  expands  to  the  Hmits  of  its  reserve  capacity. 
If,  on  the  other  hand,  as  is  often  the  case  in  early  life,  the 


18  DISEASES   OF  THE  LUNGS  AND  PLEURA 

chest  walls  be  soft  and  feeble,  they  cannot  properly  expand, 
and  a  small,  narrow,  or  distorted  chest  results. 

Lymphatics. — We  have  preferred  to  pass  on  from  the  con- 
sideration of  the  general  structure  of  the  lungs  to  a  discussion 
of  the  mechanism  of  the  respiratory  function,  and  even,  by 
way  of  illustration,  to  refer  to  some  morbid  states  of  per- 
verted respiratory  mechanism,  before  completing  the  anatomi- 
cal description  of  the  lungs  by  speaking  of  their  lymphatic 
and  nerve  supply.  This  has  been  done  with  the  view  of 
bringing  together  those  points  of  anatomy  and  function  which 
are  most  concerned  in  the  production  of  physical  signs  and 
symptoms. 

In  the  lymphatic  and  nervous  apparatus  of  the  lungs  we 
have,  so  to  speak,  the  drainage  and  function-regulating 
systems,  whose  workings  are  for  the  most  part  hidden  from 
us,  to  be  brought  to  light  mainly  through  the  manifesta- 
tions of  disease.  And,  in  truth,  the  important  part  played  in 
pathology  by  the  complex  lymphatic  system  of  the  lung,  as 
disclosed  to  us  by  the  researches  of  the  late  Sir  John  Burdon- 
Sanderson-'  and  Dr.  Klein,"  has  become  more  clearly  dis- 
cerned with  a  better  knowledge  of  the  origin  and  extension 
of  pulmonary  diseases. 

The  lymphatics  of  the  lung  take  their  origin  partly  in  a  net- 
work of  fine  vessels  which  ramify  in  the  connective  tissue  sup- 
porting the  pulmonary  lobules,  partly  in  the  mucous  mem.- 
brane  of  the  bronchi.  Those  vessels  which  surround  the 
lobules  on  the  surface  of  the  lung,  communicate  with  the 
lymphatics  of  the  visceral  pleura,  and  both  are  drained  by  the 
superficial  collecting  trunks,  which  course  over  the  surface 
of  the  organ  and  terminate  in  the  glands  at  its  root.  The 
lymphatics,  originating  in  the  deeper  lobules  and  in  the 
bronchi,  communicate  with  those  on  the  surface  of  the  organ, 
and  are  drained  by  the  deep  collecting  trunks,  which,  under 
the  name  of  "perivascular"  and  "peribronchial"  lymphatics, 
accompany  the  pulmonary  vessels  and  bronchi,  to  end  also 
in  the  glands  of  the  hilum. 

The  communication  which  exists  between  the  superficial 
lymphatics  of  the  lung  and  those  of  the  visceral  pleura  shows 
how  easily  organisms  may  be  carried  to  this  membrane,  and 
thus  lead  to  its  infection,  even  though  recent  research  casts 


ANATOMY  AND   FUNCTIONS   OF  THE  LUNGS  IQ 

some  doubt  upon  the  existence  in  the  human  subject  of 
"stomata,"  whereby  direct  communication  between  the  in- 
terior of  the  serous  membrane  and  the  lymphatics  of  the 
lung  and  pleura  was  believed  to  be  established. 

Another  point  of  great  interest  insisted  upon  by  Professors 
Poirier  and  Cuneo/'  whose  work  on  the  lymphatic  system  has 
added  much  to  our  knowledge,  is  that  the  lymphatics  of  the 
pleural  and  peritoneal  surfaces  of  the  diaphragm  communi- 
cate freely  with  each  other,  and  that  the  one  can  be  easily 
injected  from  the  other.  The  frequent  spread  of  infection 
between  the  two  serous  sacs  is  thus  explained.  Of  great 
importance,  too,  is  their  observation  that  certain  lymphatic 
vessels  from  the  liver  pass  directly  to,  and  drain  into,  the  sub- 
pleural  lymphatics  of  the  diaphragm,  thus  explaining  the 
frequent  occurrence  of  pleurisy  as  a  sequel  to  abscess  and 
other  infective  diseases  of  the  liver. 

Nerves. — The  nerve-supply  to  the  lungs  is  derived  from  the 
anterior  and  posterior  pulmonary  plexuses,  which  are  formed 
by  the  interlacement  of  branches  from  the  vagi,  joined  by 
others  from  the  sympathetic,  chiefly  from  the  inferior  cer- 
vical ganglion,  the  annulus  of  Vieussens,  and  the  ganglion 
stellatum.  The  nerves  from  these  plexuses  accompany  and 
supply  the  bronchi  and  vessels,  and  then  appear  to  end  by 
forming  a  delicate  network,  the  ultimate  fibrils  of  which  are 
distributed  upon  the  alveoli. 


REFERENCES. 

'  (i)  "  Observations    on    the    Anatomy    of    the    Lungs,"     by    Thomas 
Addison,  M.D.,  Physician  to  Guy's  Hospital.     Transactions  of  the 
Royal  Medical  and  Chirurgical  Society,  1841,  vol.  xxiv.,  p.  146. 
(2)    "A    Collection    of    the    Published    Writings    of    the   late    Thomas 
Addison,     M.D.,    p.    2,    New    Sydenham    Society's    edition,     1868 
vol.  xxxvi. 

^  Die  direkte  Laryngoshofie,  Bronchoskopie,  und  CEso-phagoskofie,  von 
Dr.  Med.  et  Phil.  W.  Briinings,  p.  216*.     Wiesbaden,  1910. 

^  "The  Structure  of  the  Lung,"  by  W.  S.  Miller,  Journal  of  Morphology, 
Boston,  1893,  vol.  viii.,  p.  165. 

*  {a)  The  Bronchi  and  Pulmonary  Bloodvessels,  by  William  Ewart,  M.D  . 
London,  i88g. 
[b)  Loc.  cit.,  p.  63. 


20  DISEASES   OF   THE  LUNGS   AND   PLEURA 

•'  Traite  d'' Anatomic  Humaine,  par  P.  Poirier  and  A.  Charpy,  tome  iv., 
2nd  fascic,  p.  486.     Paris,  1903. 

*  "  The  Causes  of  Absorption  of  Oxygen  by  the  Lungs,"  by  C.  Gordon 
Douglas,  M.B.,  and  J.  S.  Haldane,  M.D.,  F.R.S.,  Proceedings  of  the  Royal 
Society,  May,  1910.     Series  B.,  vol.  Ixxxii.,  p.  331. 

'  For  a  brief  reference  to  Dr.  Hensley's  lectures,  see  "  Effects  of  the 
Circulation  in  the  Lungs  in  Distending  the  Air-Vesicles,"  British  Medical 
Journal,  1872,  vol.  i.,  p.  677. 

'  "  Bemerkungen  zur  Physiologie  der  Athembewegungen  und  des 
Kleinen  Kreislaufes,"  von  Leo  Liebermann,  in  Wien,  Allgemeine  Wiener 
Medizinische  Zeitung,  1872,  No.  5,  p.  36. 

'  "On  the  Elasticity  of  the  Lungs,"  by  James  Carson,  M.D.,  Philo- 
sofhical  Transactions  of  the  Royal  Society,  1820,  part  i.,  p.  29. 

"  "  Beitrage  zum  Mechanismus  der  Respiration  und  Circulation  im 
gesunden  und  kranken  Zustande,"  von  F.  C.  Donders,  Zeitschrift  fiir 
Rationelle  Medicin,  1853,  N.F.,  Band  iii.,  p.  290. 

"  Lectures  on  "Dyspnoea,"  by  Hyde  Salter,  M.D.,  F.R.S.,  deUvered  at 
the  Royal  College  of  Physicians,  The  Lancet,  1865,  vol.  ii.,  p.  142. 

'^  "  Ueber  die  Druckverhaltnisse  im  Thorax  bei  verschiedenen  Krank- 
heiten,"  von  Dr.  M.  Perls,  Deutsche  Archiv  fiir  Klinische  Medicin,  1869, 
Band  vi.,  p.  i. 

"  See  A  Textbook  of  Physiology,  by  William  H.  Howell,  Ph.D.,  M.D., 
LL.D.,  p.  606.     Philadelphia  and  London,  1907. 

'*  "  Ueber  die  Athmung  in  der  Lunge,"  von  Dr.  L  J.  Mtiller,  Arbeiten 
aus  der  Physiologischen  Anstalt  zu  Leipzig,  mitgetheilt  durch  C.  Ludwig, 
1869,  p.  74.    _ 

'*  "  On  the  Probable -Rhythmical  Contraction  of  the  Bronchial  Muscular 
Coat  as  a  Factor  in  Pulmonary  Diseases,"  by  P.  Watson  Williams,  M.D., 
Lond.,  Bristol  Med.  Chir.  Journal,  vol.  xxi.,  1903,  p.  6.  See  also  Encyclo- 
fcedia  Medica,  vol.  ii.,  1899. 

'•  "  On  the  Capacity  of  the  Lungs,  and  on  the  Respiratory  Functions," 
by  John  Hutchinson.  Transactions  of  the  Royal  Medical  and  Chirurgical 
Society,  1846,  vol.  xxix.,  p.  137. 

"  Further  Advances  in  Physiology,  edited  by  Leonard  Hill,  M.B., 
F.R.S.,  p.  192.     London,  1909. 

'^  Lemons  sur  la  Physiologie  comfarie  de  la  Res-piration,  par  Paul  Bert, 
p.  359.     Paris,  1870. 

^°  Gesajjimelte  Beitrage  zur  Pathologic  und  Physiologic,  Band  i. ;  Ex-peri- 
mentelle  Untcrsuchungen,  von  Dr.   L.   Traube,  pp.    138-142.     Berlin,   1871. 

[a]  "  On  Some  Effects  of  Lung  Elasticity  in  Health  and  Disease,"  by 
R.  Douglas  Powell,  M.D.,  Transactions  of  the  Royal  Medical  and 
Chirurgical  Society,  1876,  vol.  lix.,  p.  165. 

[b)  Loc.  cit.,  p.  170. 

(i)  "Report  on  the  Communicability  of  Tubercle  by  Inoculation,"  by 
Dr.  Sanderson.  Tenth  Re-port  of  the  Medical  Officer  of  the  Privy 
Council.     London,  1869. 


20 


ANATOMY   AND    FUNCTIONS    OF   THE   LUNGS  2  J 

(2)  "  Further  Report  on  the  Inoculability  and  Development  of  Tuber- 
cle," by  Dr.  Sanderson.  Eleventh  Re  fori  of  the  Medical  Oficer  of 
the  Privy  Council.     London,  1869. 

-^  The  Anatomy  of  the   Lymphatic  System,   part  ii.,    "  The  Lung,"   by 
E.  Klein,  M.D.     London,  1875,. 

^^  Traite  d^ Anatomie  Humaine,  par  P.  Poirier  et  A.   Charpy,  tome  ii., 
p.   1248.     Paris,   1909. 


CHAPTER  II 

PHYSICAL  EXAMINATION   OF  THE   CHEST 

Before  proceeding  to  physical  examination,  preliminary  in- 
quiries have  to  be  made  into  the  health  history  of  the  patient, 
the  circumstances  which  have  led  up  to  his  present  illness,  and 
the  chief  symptoms  which  give  him  distress.  In  the  course 
of  these  inquiries  the  appearance  and  manner  of  the  patient 
may  be  noticed;  and  the  experienced  physician,  skilled  in 
the  physiognomy  of  disease,  will  thus  gain  information  of 
great  value  as  a  clue  to  the  often  confused  story  of  the 
patient,  and  in  suggesting  to  him  further  questions. 

It  would  be  folly  to  attempt  to  learn  from  a  book  the 
physiognomy  of  disease.  Clinical  study,  an  habitually  careful 
scrutiny  of  the  features  and  postures  of  actual  sufferers,  will 
alone  enable  us  to  appreciate  it.  The  student  will  early  dis- 
tinguish the  aspect  of  turgid  lividity  and  laboured  breathing 
of  chronic  bronchitis  with  dilated  heart,  from  the  pallor, 
anxiety,  throbbing  vessels,  and  dyspnoea  with  restlessness,  of 
advanced  aortic  regurgitant  disease.  The  hectic  look  of 
phthisis,  the  grave  drawn  lineaments  of  asthma,  the  puffy 
pallor  of  albuminuria,  may  in  their  more  marked  degrees  be 
soon  recognised  even  by  the  beginner.  The  finer  traits  and 
markings  of  disease,  however,  require  more  experience  for 
their  detection,  and  are  of  even  more  value  in  suggesting 
inquiries  and  often  in  leading  one  to  suspect  the  presence  of 
disease  before  sufficient  signs  can  be  found  to  justify  a  posi- 
tive diagnosis.  Incipient  tuberculosis  and  obscure  aneurism 
may  be  named  as  two  instances  in  which  the  features  of  ill- 
ness sometimes  suggest  a  more  guarded  diagnosis  than  the 
physical  signs  would  at  first  seem  to  warrant. 

The  relationship  between  physical  signs  and  the  diagnosis 

22 


PHYSICAL   EXAMINATION   OF   THE   CHEST  23 

of  pulmonary  disease  is,  again,  of  a  strictly  practical  kind, 
although  depending  upon  acoustic  principles;  and  he  who 
would  become  a  successful  auscultator  and  a  good  diagnos- 
tician must  study  auscultation  in  association  with  morbid 
anatomy.  Thus  will  the  stethoscope  reveal  to  him  at  the  bedr 
side,  in  most  cases,  an  accurate  picture  of  the  lung,  heart  or 
pleura  under  examination,  as  though  the  organ  were  exposed 
to  his  view.  This  intimate  association  in  the  mind  between 
physical  signs  and  the  lesions  which  give  rise  to  them  is  only 
to  be  acquired  by  combined  clinical  and  post-mortem  observa- 
tion; no  amount  of  reading  or  clinical  work  alone  will  suffice 
for  its  attainment. 

It  is  the  object  of  a  textbook,  however,  to  supply  certain 
data  for  comparison,  and  to  lay  down  principles  and  methods 
upon  which  a  satisfactory  exploration  of  the  chest  is  best 
founded. 

Shape  of  the  Chest.— It  is  impossible  in  a  word  to  describe 
the  shape  of  the  chest,  but  it  may  be  said  in  the  adult  to 
be  conical  from  above  downwards,  flattened  in  front,  and 
grooved  in  the  posterior  median  hne,  so  that  the  antero-pos- 
terior  diameter  is  about  one-third  less  than  the  transverse. 
In  the  child  these  two  diameters  are  more  nearly  equal.  The 
shape  of  the  upper  portion  of  the  chest  is  obscured  by  the 
pectoral  muscles  extending  from  the  upper  arm  to  the  clavicle 
and  ribs,  giving  it  a  somewhat  square  outUne.  In  the  female 
the  apparent  form  of  the  thorax  is  still  further  altered  by  the 
mammary  development. 

Measurements  of  the  Chest.— All  departures  from  the  nor- 
mal, whether  in  shape,  size  or  mobihty,  can  be  generally 
observed  by  inspection,  but  for  accuracy  in  recording  measure- 
ments are  needed.  For  this  purpose  the  double  tapes  and 
the  cyrtometer  are  of  value.  The  former  instrument  was 
introduced  into  clinical  use  by  the  late  Dr.  Charles  J.  Hare, 
Physician  to  the  University  College  Hospital,  and  consists  of 
two  tapes  connected  by  a  central  piece  for  adaptation  to  the 
spine,  from  which  point  each  tape  is  graduated.  The  back 
piece  being  carefully  held  over  the  spinous  processes,  and  a 
mark  being  made  exactly  in  the  median  line  of  the  sternum, 
the  two  tapes  are  brought  round  the  chest  at  the  same  level 
and  with  moderate  firmness  of  application,  to  overlap  one 
another  at  the  front  line,    A  comparative  measurement  of 


24  DISEASES    OF   THE   LUNGS    AND   PLEURA 

the  two  sides  is  thus  at  once  read  off,  the  sum  of  the  two 
measurements  giving  the  total  circumference. 

By  holding  the  tapes  lightly  the  expansion  of  the  chest  can 
be  measured  during  calm  breathing,  and  by  making  the 
patient  take  a  deep  breath,  followed  by  a  full  expiration,  the 
total  expansibility  is  ascertained;  also,  what  is  equally  of 
value,  the  contractility  of  the  chest  beyond  the  point  of  ordinary 
expiration.  Finally,  a  comparison  in  all  these  respects  can 
be  made  between  the  two  sides. 

By  means  of  the  cyrtometer,  a  tracing  of  the  circumferen- 
tial outline  of  the  chest  is  obtained.  This  instrument,  in  the 
form  of  jointed  whalebone,  was  first  employed  by  Woillez.^ 
Its  most  convenient  form  is  that  suggested  by  Dr.  Gee,-  and 
consists  of  two  pieces  of  thin  lead  piping-  connected  by  a 
hinge  of  rubber  tubing.  The  hinge  is  carefully  applied  over 
the  spinous  process  at  the  level  required,  and  the  piping 
moulded  round  the  chest  until  the  two  ends  cross  one  another 
in  the  median  line  in  front;  a  mark  is  then  made  and  the 
instrument  allowed  to  fall  away  from  the  chest,  being  held  by 
the  flexible  joint.  It  is  subsequently  adjusted  in  position  on 
a  sheet  of  paper,  and  "sternum"  and  "spine"  being  marked, 
the  pencil  is  carried  round  the  inner  circumference,  and  an 
exact  outline  of  the  shape  of  the  chest  is  thus  obtained,  any 
comparative  or  general  alteration  being  readily  observed. 

Callipers  are  sometimes  used  for  taking  comparative  antero- 
posterior measurements,  but,  owing  to  many  practical  diffi- 
culties, they  are  not  of  much  value  for  clinical  purposes. 

The  circumference  of  the  chest  varies  considerably  in 
different  individuals  and  within  the  range  of  health.  Thus, 
Walshe^  noted  in  adult  males  of  medium  height  measure- 
ments rang-ing  between  27  and  44  inches  in  the  circumference 
taken  opposite  the  sixth  rib.  Such  extreme  measurements 
are,  however,  exceptional.  The  admirable  statistics  of 
Baxter,*  dealing,  without  selection,  with  over  300,000  of  the 
adult  male  population  of  the  United  States,  between  the  ages 
of  eighteen  and  forty-five,  at  the  time  of  the  American  Civil 
War,  show  the  average  circumference  of  the  chest  to  be 
between  33  and  34  inches  (see  table,  p.  27).  For  cHnical  pur- 
poses these  absolute  measurements  do  not  teach  us  much. 
Relative  measurements  of  the  two  sides  are,  however,  of 
value  in  certain  diseases  attended  with  enlargement  or  dimi- 


PHYSICAL   EXAMINATION   OF   THE   CHEST  2$ 

niition  of  the  chest  on  one  side,  and  in  such  cases  cyrtometer 
tracings  are  helpful  in  giving  exact  information  also  as  to 
shape. 

The  mobility  of  the  chest  is  of  more  importance  than  its 
mere  size,  as  it  affords  a  better  indication  of  vital  capacity. 
In  the  healthy  adult  the  difference  between  extreme  inspira- 
tion and  extreme  expiration  should  not  be  less  than  2^  inches, 
as  measured  by  the  tapes  at  or  about  the  level  of  the  nipples. 
It  may  amount  to  as  much  as  5  inches.  The  difference  should 
be  nearly  equally  divided  between  the  two  sides,  a  slight 
excess  in  favour  of  the  right  being  of  no  importance. 
Vierordt,'  indeed,  states  that  in  right-handed  persons  there 
is  constantly  an  excess  of  from  i  to  i^  centimetres  (about 
•1  inch)  on  the  right  side. 

In  calm  breathing,  however,  the  actual  movement  of  the 
chest  is  very  small,  averaging  in  the  healthy  male  (according 
to  Walshe)  ^  inch  :  the  expansion  of  any  one  spot  of  the 
chest  surface  not  exceeding  2  to  3  millimetres,  as  already 
shown  (p.  12).  The  whole  subject  of  mensuration  will  be 
found  duly  discussed  in  Walshe's  treatise,  to  which  we  have 
already  referred.  For  detailed  researches  respecting  the 
movements  of  individual  ribs,  we  must  refer  the  reader  to 
Dr.  Ransome's^  monograph  on  stethometry,  and  Dr.  Arthur 
Keith's'  more  recent  work  on  the  subject. 

Pneumatometry. — The  power  ordinarily  employed  by  the 
inspiratory  and  expiratory  forces  during  calm  breathing,  and 
that  which  they  are  capable  of  exercising  during  extremest 
effort,  have  been  carefully  estimated  by  various  authors,  and 
especially  by  Waldenburg.^  Pneumatometry  and  Spirometry 
are  most  fully  discussed  in  his  work,  and  later  researches  have 
added  but  little  to  our  knowledge  of  the  subject. 

The  instrument  employed  by  Waldenburg  consisted  of  a 
manometer  provided  with  a  naso-oral  mask  so  padded  as  to 
fit  with  accuracy,  each  limb  of  the  manometer  measuring 
about  12  inches  (270  millimetres),  and  being  half  filled  with 
mercury. 

For  calm  breathing  the  mercurial  surface  would  indicate  a 
difference  of  from  i  to  2  millimetres.  With  forced  inspira- 
tory effort  the  mercury  could  be  maintained  at  a  minus  pres- 
sure of  2^  inches  (60  millimetres),  nearly  double  this  pressure 
being   momentarily    obtainable.     The    expiratory    force    ex- 


26  DISEASES   OF   THE  LUNGS   AND   PLEURiE 

ceeded  the  inspiratory  by  20  to  30  millimetres — i.e.,  with 
forced  expiratory  effort  3^  inches  (90  millimetres)  of  positive 
mercurial  pressure  might  be  maintained,  and,  momentarily,  as 
much  again. 

Marked  variations  from  the  healthy  standard  are  met  with 
in  disease,  and  in  two  directions : 

1.  The  inspiratory  power  is  diminished  whilst  the  expira- 
tory {except  in  extreme  cases)  rem^ains  normal.  This  type  is 
observed  in  phthisis,  even  in  the  earliest  stages  of  that  disease. 
It  is  found  also  in  laryngeal,  tracheal  and  bronchial  obstruc- 
tions, and  to  a  less  extent  in  pneumonia  or  in  pleuritic  effu- 
sion. 

2.  The  expiratory  pressure  is  lowered,  the  inspiratory  re- 
maining normal  or  being  even  increased,  or  subnormal,  but 
in  all  cases  remaining  relatively  higher  than  the  expiratory. 
This  type  obtains  in  emphysema,  bronchitis  and  asthma,  also 
in  diseases  of  the  abdominal  organs  which  impede  the  play  of 
the  expiratory  muscles. 

Spirometry. — In  the  healthy  adult  at  rest  the  respirations 
number  from  sixteen  to  twenty  per  minute;  they  are  some- 
what slower  during  §leep  than  when  awake,  and  are  readily 
accelerated  by  movements,  effort,  or  excitement  of  any  kind. 
With  each  act  of  calm  breathing  there  is  an  influx  into  the 
chest,  followed  by  a  corresponding  efflux,  of  some  500  c.c. 
(30  cubic  inches)  of  tidal  air.  If  the  inspiration  be  an  un- 
usually deep  one,  an  additional  1,500  c.c.  of  so-called  com- 
plemental  air  may  be  inhaled;  while,  conversely,  after  a 
normal  expiration  1,500  c.c.  of  reserve  or  supplemental  air 
may  be  still  further  expelled,  if  a  very  forcible  expiratory 
effort  be  made.  The  sum  of  these  three,  representing  the 
amount  of  air  which  can  be  expelled  by  the  deepest  expira- 
tion following  the  deepest  inspiration,  constitutes  the  vital 
capacity  of  the  individual,  and  in  a  healthy  Englishman  of 
average  build  amounts  to  rather  more  than  3,500  c.c.  (210 
cubic  inches).  Even  then,  however,  the  lungs  are  by  no 
means  airless,  some  1,000  c.c.  of  residual  air  being  still  re- 
tained within  them,  which  can  never  be  expelled  during  life. 

These  facts  were  originally  worked  out  by  Hutchinson,®''  by 
means  of  an  instrument  called  the  spirometer,  which  consisted 
essentially  of  a  graduated  gasometer  nicely  balanced  and  pro- 
vided with  a  mouthpiece,  through  which  the  patient  could 


PHYSICAL  EXAMINATION   OF   THE   CHEST 


V 


breathe  into  the  meter  previously  set  at  zero.  By  a  series  of 
elaborate  investigations,  he  arrived  at  the  following  impor- 
tant conclusions,  which  have  not  been  altered  or  materially 
added  to  since  his  original  paper. 

Hutchinson  found  that  the  vital  capacity  varied  with  the 
height  in  a  very  definite  manner,  as  will  be  seen  by  the  sub- 
joined table : 


Vital  Capacity. 

Hutchinson. 

Circumference  of  Chest. 

Height. 

From 

From 

Weight. 

(Number  of  Cases 
examined  in  Brackets  ) 

Observation. 

Calculation. 

Baxter. 

ft.  in.         ft. 

in. 

cub.  in. 

cub.  in. 

lb. 

in. 

5     o  to  5 

I 

174 

174 

120 

30-8  (1,674) 

5      I    ..    5 
3     2   .,   5 

2 

3 

177 
189 

182 
190 

126 
133 

}       3I-I  (9.871) 

5     3   ..   5 

5    4  ,,   5 

4 
5 

193 
201 

198 
206 

136 
142 

1       31-9(36,989) 

5     5  ,,   5 
5     6  .,   5 

6 
7 

214 
228 

214 
222 

145 

148 

}       32-9  (76,157) 

5     7  ,.   5 
5     8   ..   5 

8 
9 

229 
237 

230 

238 

155 
162 

}       33-6(94,450) 

5     9  ,.   5 
5  lo  ,,   5 

lO 

II 

246 
247 

246 
254 

169 

174 

1       34'2  (64,591) 

5  II   „  6 

o 

259 

262 

178 

347  (25.500) 

In  the  table  the  two  columns  of  vital  capacity — one  taken 
from  a  number  of  observations,  the  other  from  calculation — 
are  so  nearly  identical  that  we  may  take  it  that  every  inch 
in  stature  above  5  feet  should  add  8  cubic  inches  to  the  vital 
capacity.  The  last  column  has  been  added  to  show  the  cor- 
responding circumferential  measurements  of  the  chest. 

Hutchinson^*  further  showed  that  body-weight  influences 
the  vital  capacity.  At  the  height  of  5  feet  6  inches  the  vital 
capacity  increases  in  the  ratio  of  i  cubic  inch  per  pound, 
as  the  body-weight  rises  from  105  pounds  to  161  pounds 
(ii|  stone).  Above  this  Hmit,  however  (up  to  196  pounds,  or 
14  stone),  as  the  person  becomes  heavier  the  capacity  dimin- 
ishes in  the  same  proportion,  losing  i  cubic  inch  per  pound 
as  the  weight  increases. 

After  thirty  and  up  to  sixty  years  of  age,  there  is  a  decrease 
of  nearly  i^  cubic  inches  per  year  of  age.  In  disease  the  vital 
capacity  decreases  from  10  to  70  per  cent.  This  diminution  is 
dependent  upon,  but  not  directly  proportional  to,  the  extent 
Qf  breathing  surface  encroached  upon,  since  the  lung  or  por- 


28 


DISEASES    OF   THE   LUNGS   AND   PLEURA 


tion   of  lung  remaining  healthy  may  take   a   compensatory 
action  (Waldenburg). 

Topography  of  the  Chest. — For  convenience  in  clinical  ex- 
amination and  description,  the  chest  is  mapped  out  into  cer- 


1  2      3      4       5 


Fig.  6  (from  Quain's  "Anatomy"). 

A,  Upper  margin  of  sternum  =  intervertebral  disc  between  second  and 
third  dorsal  vertebras;  B,  second  costal  cartilage  =  fifth  dorsal  vertebra; 
C,  infrasternal  depression  (xiphisternal  articulation- intervertebral 
disc)  between  ninth  and  tenth  dorsal  vertebra  (spine  of  the  eighth 
dorsal  vertebra).  The  lines  of  longitudinal  parallels  are  indicated  by 
figures  and  arrows  above  the  diagram. 

N.B. — The  line  of   the  secondary  fissure  should   run   more  horizontally 
across  the  chest  at  about  the  level  of  the  fourth  rib. 


tain  regions.     These  are  sufficiently  indicated  by  the  terms 
employed,  viz. : 

Anteriorly,  the  supraclavicular,  clavicular,  infraclavicular. 
mamary  and  inframammary  regions,  on  the  right  and  left 
sides  respectively. 


PHYSICAL  EXAMINATION   OF  THE  CHEST 


29 


In    the  median   line,   the    suprasternal,   upper   sternal   and 
lower  sternal  regions. 

Laterally,  the  axillary  and  infra-axillary  regions. 


Fig  7  (FROM  Quain's  "Anatomy"). 

X,  Seventh  cervical  spine  =  apex  of  lung  ;  A,  commencement  of  great  fissure 
(apex  of  lower  lobe)=tip  of  spine  of  second  dorsal  vertebra — i.e., 
2  inches  below  summit  of  lung;  B,  bifurcation  of  trachea  — lower  part 
of  body  of  fourth  dorsal  vertebra,  or  between  the  third  and  fourth 
dorsal  spines  (level  of  junction  of  manubrium  and  gladiolus  sterni 
anteriorly);  C,  long  axis  of  spleen  =  tenth  rib;  D,  base  of  lungs^tenth 
dorsal  spine;  E,  upper  end  of  left  kidney  =  eleventh  dorsal  spine,  the 
right  being  \  inch  lower;  X=first  lumbar  spine.  The  lines  of  longi- 
tudinal parallels  are  indicated  by  figures  and  arrows  above  the 
diagram. 


Posteriorly,  the  upper  scapular  (supraspinous),  the  lower 
scapular  (infraspinous),  the  interscapular  and  the  basic 
regions  on  each  side. 


30 


DISEASES   OF  THE  LUNGS   AND  PLEURA 


For  the  purpose  of  more  accurately  noting  for  future  refer- 
ence the  locality  of  any  particular  physical  signs,  there  is  no 
better  or  simpler  plan  than  that  of  employing  imaginary  Hues 
and  levels  drawn  upon  the  chest  surface  (see  Figs.  6  and  7). 
Thus  the  chest  can  be  mapped  out  in  latitude  and  longitude 


Fig.  8. — Showing  the  Relation  of  the  Thoracic  Viscera  to  the 

Chest  Wall. 

(After  Professors  Merkel  and  Thane,  slightly  modified.) 

by  parallel  vertical  lines  drawn  from  summit  to  base  through 
the  mid-sternal  (i),  parasternal  (2),  sterno-nipple  (3),  nipple 
(4),  anterior  axillary  (5),  mid-axillary  (6),  posterior  axillary  (7), 
m,id-scapular  (8),  interscapular  (9),  and  vertebral  lines  (10), 
intersected  by  parallel  lines  drawn  horizontally  at  the  levels  of 
the  several  rib  cartilages  in  front  and  the  several  spinous  pro- 


PHYSICAL  EXAMINATION  OF  THE   CHEST 


31 


cesses  behind,   with   the   addition   of   nipple   level,   ensiform, 
level,  etc. 

A  careful  observation  of  the  accompanying  diagrams  (Figs. 
6  and  7)  will  impress  upon  the  memory  the  main  features  in 


Fig.  9. — Showing  the  Relation  of  the  Thoracic  Viscera  to  the 

Chest  Wall. 

(After  Professors  Merkel  and  Thane,  slightly  modified.) 

the  topography  of  the  chest  organs  and  of  those  of  the 
abdominal  viscera  in  immediate  relation  v/ith  the  chest.  Mar- 
ginal references  are  made  at  certain  levels  to  facts  of  topo- 
graphy, which  it  is  of  some  importance  to  bear  in  mind  in 
clinical  work.     It  will  be  observed  that  the  upper  or  anterior 


32  DISEASES    OF   THE  LUNGS   AND   PLEURA 

lobes  of  the  lungs  occupy  most  of  the  front  aspect  of  the 
chest,  whereas  posteriorly  the  lower  or  posterior  lobes  cor- 
respond with  nearly  the  whole  surface.  The  relations  of  the 
thoracic  viscera  to  the  chest  wall  are  shown  more  in  detail 
in  Figs.  8  and  9. 


REFERENCES. 

^  Recherches  Clitiiques  sur  VEmfloi  d'un  Noveau  Procede  de  Mensura- 
tion dans  la  Pleuresie,  par  E.  J.  Woillez.     Paris,  1857. 

^  Auscultation  and  Percussion,  by  Samuel  Gee,  M.D.,  p.  11.  London, 
1S70. 

3  Diseases  of  the  Lungs,  by  W.  H.  Walshe,  M.D.,  F.R.C.P.,  fourth 
edition,  p.  30.     London,  1871. 

■*  Statistics,  Medical  and  Anthro-pological,  by  J.  H.  Baxter,  A.M.,  M.D. 
Washington,  1875. 

^  A  Clinical  Textbook  of  Medical  Diagnosis,  by  Oswald  Vierordt,  M.D., 
Professor  of  Medicine  at  the  University  of  Heidelberg,  translated  by 
Francis  H.  Stuart,  M.D.,  p.  163.     London,  1891. 

^  On  Stethometry :  a  New  and  more  Exact  Method  of  Measuring  and 
Examining  the  Chest,  with  Some  of  its  Results  in  Physiology  and  Practical 
Medicine;  also  an  Affendix  on  the  Chemical  and  Microscofical  Examina- 
tion of  Resfired  Air,  by  Arthur  Ransome,  M.D.     London,  1876. 

'  "  The  Mechanism  of  Respiration  in  Man,"  by  Dr.  Arthur  Keith,  with 
bibliography,  in  Further  Advances  in  Physiology,  edited  by  Leonard  Hill, 
M.B.,  F.R.S.,  p.  182.     London,  1909. 

^  Die  fneumatische  Behandlufig  der  Resfirations-  und  Circulations- 
krankheiten,  von  Dr.  Med.  L.  Waldenburg.     Berlin,  1880. 

^   [a]  "  On  the  Capacity  of  the  Lungs  and  on  the  Respirator}'  Functions,'' 
by  John  Hutchinson,   Transactions  of  the  Royal  Medical  and  Chir- 
urgical  Society  of  London,  1846,  vol.  xxix.,  p.  137. 
[b]  Loc.  cit.,  pp.  164  and  174. 


CHAPTER   III 

PHYSICAL  EXAMINATION  OF  THE  CHEST  [Continued] 

In  physically  exploring  the  chest,  inspection,  palpation,  per- 
cussion and  auscultation  are  successively  employed. 

Inspection. 

The  chest  should  always,  if  possible,  be  uncovered,  so  that 
a  general  view  of  its  conformation  can  be  obtained.  We  may 
thus  observe  the  broad,  well-formed  chest  of  robust  health,  or 
the  small,  narrow,  long  chest  adapted  to  small  lungs,  with 
antero-posterior  and  lateral  diameters  diminished,  costal 
angle*  narrowed,  and  ribs  unduly  oblique  and  approximated; 
or,  again,  the  thorax  may  be  expanded,  with  widened  inter- 
costal spaces,  straightened  ribs,  increased  costal  angle,  and 
deepened  antero-posterior  diameter — making  up  the  round- 
shouldered,  barrel-shaped  chest  suited  to  the  accommodation 
of  enlarged  lungs.  Further,  the  thorax  may  be  distorted  by 
various  kinds  of  spinal  curvature,  by  rickets  in.  early  life,  or 
by  continued  pressure  in  any  particular  direction.  Finally, 
there  may  be  local  flattenings  or  bulgings  of  the  chest  walls, 
due  to  alterations  in  the  subjacent  viscera,  and  giving  rise  to 
a  want  of  symmetry  on  the  two  sides. 

The  jnovcments  of  the  chest  are  of  great  importance  in 
diagnosis.  The  free  and  equable  expansion  of  the  chest 
implies  the  free  entry  of  air  into  the  lungs ;  on  the  other  hand, 
relative  immobility  or  recession  of  any  portion  of  the  chest 
during  inspiration  signifies  that  the  entry  of  air  to  the  corres- 
ponding portion  of  lung  is,  from  some  cause,  retarded  or 
impeded.  In  cases  of  general  obstruction  to  the  entry  of  air, 
whether  by  impediment  at  the  main  air-passage  or  through- 

*  The  angle  formed  by  the  inferior  margins  of  the  chest  at  the  ensiform 
cartilage.     This  angle  should  measure  nearly  go  degrees. 

33  3 


34  DISEASES   OF  THE  LUNGS  AND   PLEURA 

out  the  bronchial  tract,  there  is  universal  recession  of  all  the 
soft  parts  during-  inspiration — the  supraclavicular  regions  sink 
downwards,  the  hypochondria  recede,  and  the  intercostal 
spaces  deepen  during  the  effort  to  expand  the  chest  against 
atmospheric  pressure.  When  the  difficulty  of  expansion, 
whether  from  intrinsic  disease  of  the  lung  or  pleura,  or  from 
obstruction  of  air-passages,  is  restricted  to  one  side  of  the 
chest  or  to  a  portion  of  one  lung,  the  restrained  expansion 
during  inspiration  is  limited  to  that  portion.  Thus  from 
inspection  alone  we  may  often  form  an  opinion  as  to  the  seat, 
and  even  surmise  the  nature,  of  the  disease  present. 

Various  instruments  which  have  already  been  referred  to — 
callipers,  cyrtometer,  double  tapes — are  valuable  for  the  pur- 
pose of  recording  differences  in  shape  and  measurement,  but 
the  information  which  they  are  useful  in  recording  is  at  once 
obtained  by  the  eye  of  the  trained  observer. 

By  inspection  we  thus  learn  :  (i)  whether  a  patient  be  large- 
chested  or  small-chested;  (2)  whether  the  shape  of  the  chest 
be  good  and  symmetrical,  deformed,  flattened,  or  bulged  in 
any  of  its  parts;  (3)  whether  its  movements  be  free  and 
equable,  or  irregular  and  restricted,  generally  or  locally,  and 
whether  increased  or  diminished  in  frequency.  Lastly,  any 
surface  markings,  such  as  enlarged  veins,  tumours,  or  abnor- 
mal pulsations,  will  at  once  attract  the  eye  and  be  duly  noted. 

Palpation. 

Palpation  is  employed  in  aid  both  of  inspection  and  per- 
cussion. 

(a)  During  preliminary  inspection  of  the  chest  the  position 
of  the  heart's  apex-beat  should  invariably,  and  as  a  matter  of 
habit,  be  ascertained,  and  any  deviation  from  its  normal  posi- 
tion— viz.,  the  fifth  intercostal  space  half  an  inch  to  the  sternal 
side  of  the  left  nipple  Hne — should  be  noted. 

(b)  Any  local  bulg'ing  or  tumour  will  naturally  be  manipu- 
lated to  ascertain  its  relation  with  bone  or  soft  structure, 
whether  it  be  solid,  fluctuating,  or  pulsating;  also  any  tender- 
ness will  be  observed. 

(c)  The  expansion,  symmetrical  or  otherwise,  of  the  two 
sides  will  be  observed  by  placing  the  hands  evenly  on  the  two 
sides  of  the  chest. 


PHYSICAL   EXAMINATION   OF   THE   CHEST  35 

(d)  In  connection  with  percussion  the  observer  should 
notice  differences  of  resistance  as  well  as  of  tone. 

(e)  Increase  or  diminution  of  vocal  znbration  or  fremitus 
will  be  noted  over  any  spot  of  altered  resonance  by  applying 
the  hand,  and  making  the  patient  utter  some  resonant  words, 
such  as  "  ninety-nine." 

Vocal  fremitus  is  increased  by  consolidation  of  lung,  pro- 
vided the  bronchi  be  not  occluded;  diminished  by  much  thick- 
ening of  the  pleura,  by  obstruction  of  the  main  bronchus,  or 
by  air  in  the  pleura ;  annulled  by  fluid  in  the  pleura,  if  in  suffi- 
cient quantity.  The  loudness  or  feebleness  of  the  voice,  as 
well  as  height  or  depth  of  pitch,  must  of  course  be  taken  into 
account  in  judging  of  fremitus,  and  corresponding  parts  on 
the  two  sides  should  always  be  compared.  Any  vibration 
from  above  can  be  checked  by  applying  one  hand  lightly  and 
edgewise  to  the  chest  above  the  part  which  is  being  palpated. 

(/)  Loud,  coarse,  bronchial  rales  may  cause  the  chest  walls 
to  vibrate  perceptibly,  producing  rhonchal  fremitus;  some- 
times cavernous  or  large  crackling  rales  will  do  the  same. 
Pleuritic  friction  may  likewise  be  perceptible  to  the  hand — 
friction  fremitus.  In  cases  of  effusion  into  the  pleural  cavity, 
or  in  hydatid  cysts  n^ar  the  surface,  fluctuation  may  some- 
times be  elicited. 


Pp:rcussion. 

Percussion  is  the  method  by  which  we  test  the  resonance  of 
various  parts  of  the  thorax,  and  compare  it  with  that  which 
experience  has  found  to  obtain  in  health.  The  varying 
deg'rees  of  resonance  depend  upon  the  relative  amount  of  air 
and  soHd  structure  subjacent,  and  upon  other  causes  to  be 
incidentally  noticed. 

It  is  interesting-  to  note  that  while  inspection  and  palpation 
have  been  practised  since  the  earliest  times,  percussion,  as  a 
means  of  diagnosis  in  diseases  of  the  chest,  is  of  compara- 
tively recent  origin.  It  was  first  employed  by  Auenbrugger,^ 
a  Physician  of  Vienna,  in  1761,  but  its  importance  was  mis- 
understood, and  it  was  not  until  1808,  ten  years  before  the 
discovery  of  auscultation  by  Laennec,  that  Corvisart,  of  Paris, 
Laennec's  teacher,  brought  Auenbrugger's  forgotten  work 
to  notice,  and  the  method  came  into  general  use.-" 


36  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

Method  of  Percussing. — It  is  best  to  use  the  fingers  only 
for  percussing.  One  finger  of  the  left  hand  should  be  placed 
firmly  upon  the  chest  so  that  the  two  last  phalanges  are 
accurately  applied  to  the  part  percussed.  With  one  or  two 
of  the  fingers  of  the  right  hand,  semi-flexed,  the  percussion 
should  be  made,  so  that  the  stroke  fall  vertically  upon  the 
applied  or  pleximeter  finger.     Be  it  observed:  — 

1.  That  the  pleximeter  finger  be  applied  accurately  and 
with  sufficient  firmness. 

2.  That  it  be  applied  precisely  in  the  same  manner  and  to 
the  same  spot  on  the  corresponding  sides  of  the  chest  in 
comparing  them;  for  instance,  the  finger  must  not  be  applied 
along  the  intercostal  space  on  one  side,  and  across  the  ribs 
on  the  other. 

3.  The  percussion  stroke  must  be  made  from  the  wrist, 
quite  vertical  to  the  surface  percussed,  and  in  comparing  two 
spots  the  force  of  percussion  must  be  the  same.  These  con- 
ditions cannot  be  nearly  so  well  preserved  if  percussion  be 
made  from  the  elbow. 

4.  As  a  rule,  the  percussion  stroke  should  be  light.  The 
precise  limits  of  dulness,  whether  in  chest  or  abdomen,  can- 
not be  ascertained  by  hard  percussion,  since  the  vibrations 
of  collateral  parts  are  too  strongly  elicited.  It  is  laid  down 
in  most  textbooks  that  percussion  should  be  made  "  stac- 
cato," the  percussion  finger  not  being  allowed  to  rest  upon 
the  pleximeter.  This,  we  are  convinced,  is  an  error,  which  is 
avoided  by  non-observance  by  nine  out  of  ten  of  the  best 
manipulators  in  actual  practice.  It  is  sometimes,  of  course, 
advisable  to  employ  the  lightest  possible  staccato  percussion, 
and  it  is  also  sometimes  necessary  to  employ  hard  percussion 
to  elicit  dulness  or  resonance  of  deep-seated  parts. 

5.  The  sense  of  touch  must  be  used  equally  with  that  of 
hearing  in  percussion,  and  the  degrees  of  resistance  appre- 
ciated by  the  pleximeter  finger  are  to  be  carefully  noted.  In 
this  way  the  hardness  and  want  of  resilience  over  dense  sub- 
jacent tissues  may  be  readily  felt. 

Various  pleximeters  and  plessors  are  used  by  some 
observers,  modifications  of  those  originally  designed  by 
Piorry.^  The  simplest  pleximeter  consists  of  a  piece  of  ivory 
some  two  inches  long  and  half  an  inch  broad,  the  plessor 
being  a  small  hammer  with  an  india-rubber  tip  to  the  striking 


PHYSICAL  EXAMINATION  OF  THE   CHEST  37 

surface.  These  instruments  may  be  of  value  in  demonstrat- 
ing to  a  class,  but  their  employment  by  students  should  not 
be  encouraged  for  three  reasons  : 

1.  We  may  rely  upon  having  our  fingers  with  us,  but  are 
apt  to  leave  detached  instruments  behind. 

2.  Patients  when  very  ill  are  frightened*  or  annoyed  by 
instruments,  and  may  be  readily  hurt  by  them. 

3.  The  important  reason  is,  however,  that  in  using  such 
instruments  we  deprive  ourselves  altogether  of  the  informa- 
tion gained  by  the  sense  of  resistance.  Some  physicians  are 
inclined  of  late  to  take  to  the  pleximeter,  still  using  the  fingers 
as  the  plessor;  but  inasmuch  as  it  is  the  pleximeter  finger  with 
which  we  chiefly  appreciate  resistance,  the  objection  in 
greatest  measure  still  holds  good. 

The  position  of  the  patient  during  physical  examination  of 
the  chest  by  percussion  and  auscultation  is  of  importance. 
If  not  in  bed,  the  sitting  posture,  with  the  back  supported  by 
a  cushioned  chair,  is  the  best  for  examining  the  front  o'f  the 
chest;  if  in  bed,  the  semi-reclining  posture  with  the  back 
firmly  supported.  Whilst  the  back  is  being  examined  the 
patient  should  be  directed  to  lean  slightly  forward,  and  to 
let  the  arms  fall  loosely  down  between  the  knees,  in  which 
position  the  suprascapular  regions,  at  which  the  summits  of 
the  lungs  aj-e  situated,  are  best  exposed.  If  the  patient  stoops 
forward  too  much  with  folded  arms  and  bent  back,  the  respira- 
tory movements  are  impeded,  and  a  very  considerable  amount 
of  dulness  may  be  developed  at  the  right  base  by  the  thrust- 
ing backwards  of  the  upper  posterior  surface  of  the  liver. 

Each  region  of  the  chest  surface  should  be  systematically 
tested  by  percussion,  the  two  sides  of  the  chest  being  at  all 
points  compared.  Not  only,  however,  must  the  two  sides  of 
the  chest  be  thus  compared  from  above  downwards,  but  per- 
cussion should  be  employed  from  side  to  side  across  the 
sternum,  so  as  to  define  the  limits  of  the  anterior  margins  of 
the  lungs  from  either  side.  By  this  means  valuable  informa- 
tion is  often  elicited  in  cases  of  consumption,  new  growths, 
and  pleuritic  effusions.  It  is  useful  in  practice,  having  ascer- 
tained the  lower  limit  of  resonance,  to  direct  the  patient  to 
make  a  full  inspiration  and  expiration  whilst  repeated  light 
percussions  are  being  made.  The  pleximeter  finger  can  fol- 
low up  and  down  the  level   of  resonance,  and  in  this  way 


38  DISEASES   OF  THE  LUNGS   AND   PLEURA 

valuable  information  as  to  the  mobility  of  the  diaphragm  and 
expansibility  of  the  bases  of  the  lung  can  be  obtained. 

In  the  healthy  chest  we  obtain  during  moderate  expiration 
superficial  cardiac  dulness.  This  corresponds  roughly  with 
a  triangular  area,  marked  off  by  a  line  curving  outwards 
towards  the  apex,  from  the  lower  margin  of  the  fourth  left 
costal  cartilage  at  its  junction  with  the  sternum,  by  a  second 
line  running  vertically  down  the  centre  of  the  sternum,  whilst 
the  base  is  formed  by  a  horizontal  line  passing  from  the 
apex-beat  to  the  mid-sternum.  On  firm  percussion  the  deep 
cardiac  dulness  may  be  elicited  as  high  as  the  third  left  carti- 
lage and  the  rig^ht  margin  of  the  sternum.  Stomach  note  is 
obtained  at  the  sixth  costal  cartilage  in  the  left  mid-sterno- 
nipple  line;  and  in  the  left  postero-axillary  line  a  small  area 
of  dulness  extending  from  the  ninth  to  the  eleventh  rib  and 
reaching  to  within  two  inches  of  the  middle  line  posteriorly, 
marks  the  situation  of  the  spleen.  On  the  right  front  of  the 
chest,  in  the  nipple  line,  liver  dulness  is  elicited  below  the  level 
of  the  sixth  rib,  and  on  deep  percussion,  for  a  rib  higher; 
posteriorly  about  two  fingers'  breadth  of  dulness  at  the 
extreme  right  base  marks  that  portion  of  the  liver  which  is 
here  in  contact  with  the  chest  wall.  Lung  resonance  is 
obtained  anteriorly  as  high  as  the  supraclavicular  fossa,  and 
posteriorly  extends  upwards  to  the  level  of  the  seventh  cer- 
vical spine,  i.e.,  about  one  and  a  half  inches  above  the  level 
of  the  clavicle.  It  is  in  these  higher  regions  of  the  chest, 
corresponding"  with  the  apices  of  the  lungs,  that  the  first 
evidence  of  tuberculous  disease  is  usually  detected. 

In  disease  the  percussion  note  is  altered  in  various  ways,  as 
may  be  seen  from  the  following  table,  which  includes  all  the 
terms  used  in  a  technical  sense,  which  are  necessary  for 
describing"  the  sounds  met  with  in  diseases  of  the  chest.  They 
are — with  one  or  two  unimportant  additions — those  which 
were  carefully  selected  by  the  late  Dr.  Mahomed  and  by  Dr. 
Douglas  Powell,  acting  as  English  members  of  a  committee 
nominated  at  the  International  Medical  Congress  held  in 
London  in  1881,  to  endeavour  to  simplify  the  terminology  o; 
auscultation  for  international  use. 


PHYSICAL  EXAMINATION  OF  THE  CHEST 


39 


Terms. 


PALPATION. 

Vocal  fremitus. 
Normal. 


Increased. 
Diminished. 


Absent. 


Rhonchal  fre- 
mitus. 


Friction     fre- 
mitus. 


PERCUSSION. 

Normal    reso- 
nance. 


Increased    re- 
sonance. 

Tympanitic 
resonance. 

Skodaic   re- 
sonance. 


Impaired     re- 
sonance. 


Absence      of 
resonance. 


Amphoric    re- 
sonance. 


Definition. 


The  transmission  of 
laryngeal  vibrations 
to  the  chest  wall,  ap- 
preciable by  the 
hand. 


Transmission  of  the 
vibration  of  rhonchus 
to  the  hand  applied 
to  the  chest. 

Transmission  of  the  vi- 
brations of  pleuritic 
friction. 


An  arbitrary  term  sig- 
nifying the  varying 
degrees  of  resonance 
of  the  different  parts 
of  the  chest  within 
the  range  of  health. 


Drum-like  note. 


A  peculiar  form  of  tym- 
panitic resonance  of 
high  pitch  and  great 
clearness. 


The  modified  impair- 
ment of  resonance 
sometimes  elicited 
over  a  cavity,  and 
often  accompanied  by 
"  cracked -pot  sound 
{hniit  depot/ele). 


Synonyms. 


•        • 


•         ■ 


Hyper-resonance. 


Relaxed  lung  note. 


Dulness  of  different 
degrees.  Hardness. 
Wooden  percussion. 


Absolute  dulness.  Tone- 
lessness.     Flatness. 


Tubular  note. 


Common 
Significance. 


Consolidation  of  lung. 

Bronchial  obstruction, 
or  separation  of  lung 
from  parietes  by 
thickened  pleura. 

Effusion  of  fluid  or  air 
in  the  pleural  cavity. 

Partial  obstruction  of 
larger  bronchi.  Bron- 
chitis. 


Pleuritic  roughening. 


Health  : — needs  confir- 
mation by  other 
signs. 


Air  in  the  pleural  ca- 
vity. 

Lung  in  contact  with 
chest  wall  rel.-i.\ed, 
but  not  compressed, 
by  moderate  effusion 
into  the  pleura.  Cen- 
tral consolidation  in 
pneumonia  will  some- 
times produce  this 
note. 

Incomplete  consolida- 
tion ;  coexisting  in- 
creased resistance 
may  often  be  appre- 
ciated during  per- 
cussion. 

Consolidation  of  lung, 
or  its  displacement  by 
fluid  or  tumour. 

Pulmonary  excavation 
near  the  surface  and 
freely  communicat- 
ing with  the  bronchi. 
Normally  obtained 
on  •  percussing  the 
trachea  with  the 
glottis  open. 


40 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


Terms. 


Definition. 


AUSCULTA- 
TION. 
Breath-sounds. 
Vesicular. 


Exaggerated. 


Weak. 

Suppressed. 

Interrupted. 


Prolonged 
expiration. 


Broncho- 
vesicular. 


Bronchial. 


Inspiratory  sound  soft 
and  breezy  ;  expira- 
tory sound  shorter, 
weaker,  or  even  ab- 
sent. There  should 
be  no  perceptible 
pause  between  the 
inspiratory  and  expi- 
ratory sounds. 

Intensified  normal 

breath-sound,  due  to 
increased  movement 
of  tidal  air. 


Deficient  movement  of 
tidal  air. 


Inspiratory  sound  par- 
tially or  completely 
divided  into  two  or 
three  sounds. 


Expiration  lengthened 
to  or  beyond  duration 
of  inspiration. 

The  vesicular  part  of 
the  breath  -  sound 
being  partially  an- 
nulled, the  tubular 
or  glottic  portion 
of  that  sound  is 
heard  with  greater 
distinctness,  especi- 
ally during  expira- 
tion which  is  pro- 
longed. 

A  blowing  breath-sound, 
the  inspiration  and 
expiration  being 

about  equal  in  pitch 
and  duration,  and 
distinctly  divided. 
Placing  mouth  in 
pKJsition  to  pro- 
nounce word  com- 
mencing with  gut- 
tural ch  (x),  and 
drawing  breath  to 
and  fro,  imitates  the 
sound  with  exact- 
ness (.Skoda). 


Synonyms. 


Normal  breath-sounds. 


Puerile.  Compensatory. 
Supplementary. 


Feeble.       Partial    sup- 
pression. 

Absence      of      breath- 
sounds. 


Jerking.  Wa\-j'.  Cog- 
wheeled.  Respira- 
tion saccadic. 


Common 

SiGNIFICANXE. 


Harsh.     Coarse, 
tubular. 


Sub- 


Healthy  lung. 


Tubular.  Blowing. 

Tracheal.  May  be 
high-pitched  or  whif- 
fing, medium,  or  low- 
pitched. 


Increased  function. 
When  heard  over  a 
portion  of  one  lung 
signifies  compensa- 
tory action  to  make 
up  for  deficiency  or 
disease  elsewhere. 
Normal  in  young 
children,  and  in  adults 
during  violent  exer- 
cise of  the  lungs. 

Diminished  function. 


Lung  distant  from  .sur- 
face, or  bronchus  ob- 
structed. 

Irregular  expansion  of 
lung  from  partial 
consolidations^  about 
small  bronchi  ;  but 
often  of  purely  ner- 
vous origin  through 
irregular  contraction 
of  muscles. 

Partial  consolidat'on  of 
lung  or  partial  ob- 
struction of  bronchi. 

Commencing  consolida- 
tion. Some  authors 
use  the  term  as 
descriptive  of  the 
roughened  breath- 
sound  of  dry  catarrh 
of  the  larger  bronchi. 
(Heard  normally  in 
neighbourhood  of 
bronchi.) 


Hepatisation  or  con- 
densation of  the  lung. 
(Heard  typically  over 
trachea.) 


PHYSICAL  EXAMINATION  OF  THE  CHEST 


41 


TERiVIS, 


Breath-sounds 
{continued). 
Cavernous. 


Amphoric. 


Adventitious 
.sounds. 
Rales. 


Varieties — 
I.  Dry  rales. 
Sonorous 
rale. 


Sibilant 
rale. 


Sonoro-sibi- 
lant  rale. 

Stridor. 


2.  Moist  rales. 


Small    bub- 
bling rale. 


Medium  and 
large 
bubbling 
rales. 


Definition. 


A  blowing  breath-sound 
of  hollow  quality, 
most  so  in  the  expi- 
ratory portion,  which 
is  usually  of  lower 
pitch  than  the  in- 
spiratory. 

Similar  to  the  above, 
but  -.vith  blowing 
character  and  hol- 
lowness  intensified. 


Adventitious  sounds 
produced  in  the  bron- 
chi and  lungs  under 
diseased  conditions 
by  the  passage  back- 
wards and  forwards 
of  the  tidal  air. 


A  low-pitched,  loud, 
snoring  sound,  pro- 
duced by  partial  ob- 
struction in  a  large 
bronchial  tube,  which 
imparts  vibrations 
to  the  air-current. 

A  high-pitched,  whist- 
ling sound,  produced 
in  the  same  manner 
as  the  rhonchus,  but 
in  a  smaller  tube. 


The  commingling  of  the 
two  former  sounds. 

A  coarse,  vibrating 
rhonchus,  generated 
at  the  larynx,  or  by 
pressure  on  the  tra- 
chea or  main  bron- 
chus. 


Moist  sounds  or  rattles, 
produced  by  the  bub- 
bling of  air  through 
fluid  in  the  bronchi 
or  lung. 

A  rale  produced  by 
the  bubbling  of  air 
through  fluid  in  the 
finer  bronchi,  and 
more  or  less  muflled 
by  transmission 

through  spongy  lung. 

Similar  rales  generated 
in  the  larger  tubes. 


Synonyms. 


Rhonchus. 


Sibilu 


Stridulous  rhonchus. 


Common 
Significance. 


Liquid  rales.   "Mucous 
rales  "  of  Laennec. 


Tracheal  rattles. 


Pulmonary  excavation, 
or  condensed  lung 
with  dilated  bron- 
chus. 


Large  pulmonary 
cavity  ;  sometimes 
heard  in  pneumo- 
thorax. 


Bronchitis  of  the  larger 
air-tubes. 


Bronchitis,  or  spas- 
modic narrowing  of 
the  medium  or  fine 
tubes. 


Pressure  of  a  malign "  nt 
or  aneurismal  tu- 
mour upon  trachea 
or  main  bronchus, 
sometimes  produced 
by  laryngeal  para- 
lysis. 


Capillary        bronchitis. 
Pulmonary  oedema. 


Bronchitis  of  the  larger 
tubes.  Secretion  col- 
lecting in  trachea 
during  last  moments 
of  life. 


42 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


Terms. 


Adventitious 
sounds  {con- 
tinued). 
Small     crack- 
ling rale. 


Medium 
crackling 
rales. 

Larger  crack- 
ling rales. 


Gurgling 
rales. 


Clicking 
sounds. 


3.  Fine-hair  cre- 
pitation. 


Metallic 
tinkling. 


Splash, 


Definition. 


Synonyms. 


A  fine  rale  produced  in 
the  minute  bron- 
chioles of  consoli- 
dated lung,  consist- 
ing of  numerous 
small,  sharply  de- 
fined crackles,  chiefly 
audible  during  in- 
spiration, but  in  less 
degree  w.th  expira- 
tion. 

Similar  to  above,  but  of 
larger  size. 


Crackles  of  larger  size, 
and  fewer  in  number, 
produced  in  connec- 
tion with  minute  pul- 
monary cavities. 

Larger  and  more  liquid 
rales,  produced  in- 
connection  with  cavi- 
ties of  medium  and 
large  size. 

Single  sounds,  or  few 
in  number,  mostly 
limited  to  inspira- 
tion, and  of  sticky, 
semi-fluid  character. 

A  minute  dry  crackling 
sound,  in  which  the 
crackles  are  infinitely 
small  and  even,  and 
occupy  chiefly  the 
latter  part  of  inspira- 
tion ;  produced  by 
the  separation  of 
sticky  alveolar  walls 
which  had  previously 
been  in  contact. 


The  metallic  resonance 
sometimes  imparted 
to  a  moist  sound  by 
a  large  pulmonary  or 
other  cavity.  The 
sound  may  be  gene- 
rated in  the  cavity 
or  resonated  from  a 
bronchus  in  connec- 
tion with  It. 

The  succussion  of  air 
and  fluid  in  a  large 
cavity,  produced  by 
the  shock  of  cough  or 
by  shaking  a  patient, 
with  the  ear  applied 
directly  to  the  chest 
wall. 


Subcrepitant  rale. 


Crepitations.  Crepi- 
tant rale.  Sharp 
crepitations. 


Cavernous  rales. 


Pneumonic  crepitation. 


Hippocratic  succussion 

sound. 


Common. 
Significance. 


Thin  fluid  in  minute 
bronchial  tubes,  with 
consolidation  of  the 
surrounding  lung — 
e.g.,  resolving  pneu- 
monia. 


Resolving  pneumonia, 
broncho  -  pneumonia, 
or  softening  tubercle. 

Softening  tubercle. 


Cavity  in  the  lung. 


Commencing  softening 
of  tuberculous  de- 
posits in  the  lung. 


Early  stage  of  pneu- 
monia. The  sound 
is  sometimes  heard 
in  a  certain  degree  of 
pulmonary  oedema, 
and  during  the  first 
two  or  three  deep 
inspirations  over  a 
portion  of  lung  not 
recently  used — e.g., 
the  extreme  bases 
in  bed  -  ridden  pa- 
tients. 

Pneumothorax,  or  large 
pulmonary  cavity. 


A  large  cavity  contain- 
ing air  and  fluid. 
Hydro-  or  pyopneu- 
mothorax. 


PHYSICAL  EXAMINATION   OF  THE  CHEST 


43 


Terms. 


Adventitious 
sounds  {con- 
tinued). 
Bell  sound. 


Friction. 


Dry  friction. 


Moist  friction. 


VOICE-SOUNDS 

Normal. 


Increased     or 
diminished. 

Annulled      or 
absent. 


Bronchophony 


Pectoriloquy. 


^gophony. 


Amphoric  echo. 


Definition, 


A  metallic  ring  heard 
on  sharp  percussion 
over  a  pneumo- 
thorax, commonly 
elicited  by  the  use  of 
coins. 

A  rubbing  sound  pro- 
duced by  the  move- 
ments of  two  sur- 
faces of  the  pleura 
which  are  in  contact 
and  inflamed. 


A  sound  often  closely 
imitating  moist  cre- 
pitation, produced  by 
the  attrition  of  sur- 
faces covered  by  soft, 
moist  lymph. 


The  sound  of  the  voice 
transmitted  through 
the  healthy  lung. 


Synonyms. 


Bruit  d'airain. 


Leathery    or    creaking 
friction.     Dry  rmb. 


.Spongy  friction.     Fric- 
tion crepitus,  etc. 


The  loud  transmi.ssion 
of  the  laryngeal  vi- 
brations, apart  from 
articulation. 

The  clear  transmi.ssion 
of  articulate  sounds. 
Heard  best  during 
whispering,  when 
bronchophony  (which 
usually,  but  not 
always,  accompanies 
it)  is  excluded. 


A  modified  Ijroncho- 
phony,  having  a 
high-pitched,  tremu- 
lous character,  pos- 
sibly due  to  the 
transmission  of  the 
upper  tones  or  har- 
monics, the  funda- 
mental tones  being 
intercepted. 

An  echoing  character 
accjuired  by  the 
voice  sounds  when 
conveyed  through  a 
large  air-containing 
cavity. 


Metallic  echo. 


Common 
Significance. 


Pneumothorax. 


Pleurisy. 


Heard  at  commence- 
ment and  at  termina- 
tion of  pleuritic 
attack. 

Sometimes  heard  over 
upper  confines  of  re- 
cedsnt  effusion  and 
in  other  conditions  of 
thick,  moist  pleuritic 
exudations. 


Lung  separated  from 
chest  wall  by  fluid  or 
growth. 

Pulmonary  consolida- 
tion. 


Cavity  in  the  lung.  A 
close  imitation  of 
the  sonnd—pectori- 
loguie  apho7tique — 
may  be  sometimes 
heard  through  a 
pleuritic  effusion 

(sero  •  fibrinous)  on 
making  the  patient 
whisper  roughlj'. 

Pleuritic  effusion. 


Pneumothorax. 


44 


DISEASES  OF  THE  LUNGS  AND  PLEURA 


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46  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Theory  of  Percussion. — The  exact  explanation  of  the  sounds 
elicited  by  percussion  of  the  chest  in  varied  conditions  is  by 
no  means  easy,  but  four  factors  are  concerned  in  their  pro- 
duction. These  are — (i)  the  proportion  of  air  and  solid  under 
percussion;  (2)  the  range  of  vibration  of  the  chest  wall;  (3) 
the  vibration  of  the  air  within  the  region  covered  by  the  chest 
walls,  whether  contained  in  the  lung,  bronchi,  pleura  or 
stomach;  (4)  the  tension  of  the  air  within  the  chest. 

The  late  Dr.  C.  J.  B.  Williams  and  Dr.  Bristowe  both 
regarded  the  percussion  note  as  primarily  due  to  the  vibration 
of  the  chest  wall,  and  as  modified  only  by  the  conditions  of 
the  underlying  cavities  or  viscera  so  far  as  they  afford  vary- 
ing degrees  of  impediment  to  the  chest  wall  vibration.  This 
view  cannot  be  accepted  in  its  entirety,  seeing  that  percus- 
sion of  the  lung  outside  the  body  yields  a  note  closely  resem- 
bling that  of  the  thoracic  sound.  It  is  evident,  therefore, 
that  the  resonant  note  over  healthy  lung  must  be  produced 
in  great  part  by  the  vibrations  of  the  air  within  the  lung  itself, 
though  these  vibrations  are  doubtless  supplemented  by  those 
originating  in  the  chest  wall.  Conversely,  in  disease,  when 
the  lung  is  rendered  solid  by  inflammation,  or  compressed  by 
fluid,  the  vibrations  of  the  chest  wall,  so  far  from  being  rein- 
forced, are  damped,  and  a  dull  percussion  note  results. 

But  although  the  rhythmic  vibrations  of  the  chest  are  not 
the  only  factors  in  the  production  of  the  resonant  note  of 
health,  as  was  once  held,  their  importance  must  not  be  over- 
looked, for  in  disease,  and  even  within  the  range  of  health, 
there  are  many  states  in  which  impairment  of  resonance  is  to 
be  accounted  for  only  by  a  diminished  resilience  of  the  chest 
wall.  Thus,  many  robust  people,  soldiers  especially,  have 
rigid  resisting  chest  walls,  and  percussion  in  such  persons 
yields  a  diminished  sound.  On  the  other  hand,  in  children 
and  in  delicate  persons,  with  thin  elastic  ribs,  we  may  obtain 
an  amount  of  resonance  which  may  even  mask  a  certain 
degree  of  underlying  disease.  Again,  in  cases  of  deformity 
of  the  chest,  such  as  lateral  curvature  of  the  spine,  the  note 
over  the  prominence  of  the  ribs  posteriorly  is  generally,  as  the 
late  Dr.  Hilton  Fagge  pointed  out,  much  impaired,  although 
the  underlying  lung  be  healthy,  a  fact  which  can  only  be 
explained  by  the  diminished  vibrating  capacity  of  the  chest 
wall. 


PHYSICAL  EXAMINATION   OF  THE   CHEST  47 

We  may  now  turn  to  the  last  factor  of  which  we  have 
spoken,  the  tension  of  the  air  within  the  chest.  This  is  of 
less  importance  than  the  preceding  ones,  but,  nevertheless, 
must  be  taken  into  consideration.  Thus,  in  the  well-formed 
chest  of  the  young  adult,  and  within  the  range  of  normal 
conditions  of  quiet  breathing,  we  obtain  over  the  pulmonary 
regions  that  degree  of  resonance  and  clearness  of  percussion 
which  is  typical  of  health.  At  any  stage  of  the  inspiratory 
act,  however,  the  percussion  note  is  somewhat  deadened  by. 
closure  of  the  glottis  and  compression  of  the  chest  by  the 
expiratory  muscles,  the  tension  of  the  confined  air  being 
increased,  and  its  vibratility  and  that  of  the  chest  wall  dimin- 
ished. In  pneumothorax,  again,  with  free  communication 
with  a  bronchus  (when,  therefore,  the  air  has  approximately 
the  normal  atmospheric  tension),  we  obtain  a  deep-toned  per- 
cussion note,  the  so-called  "tympanitic  resonance."  If,  how- 
ever, the  communication  with  the  lung  be  only  by  a  valvular 
opening,  admitting  the  entry,  but  not  the  escape,  of  air, 
increased  tension  of  the  air  and  of  the  chest  wall  results,  with 
corresponding  deadening  of  the  note. 

Auscultation. 

This  method  of  physical  examination  was  not  wholly  un- 
known to  the  ancient  Greek  physicians,  who  were  in  the  habit 
of  applying  the  ear  directly  to  the  chest,^  and  had  thus  dis- 
covered the  creaking  sound  of  pleural  friction,  and  also  the 
succussion  splash.  Curiously  enough  no  further  progress 
was  made,  and  with  the  dark  ages  the  method  fell  into 
oblivion,  until  Laennec,  in  the  early  years  of  the  last  century, 
rediscovered  it,  and  worked  out  its  appHcation  to  disease  even 
in  its  minutest  details.  To  him,  therefore,  belongs  the  honour 
of  being  regarded  as  the  true  discoverer  of  auscultation,  and 
the  publication  of  the  first  edition  of  his  great  work,  "  Traite 
de  I'Auscultation  Mediate,"  in  1819,  must  ever  remain  a  land- 
mark in  the  history  of  medicine. 

Auscultation  may  be  practised  by  using  the  unaided  ear 
applied  directly  to  the  chest,  or  separated  from  it  only  by  a 
towel  (immediate  auscultation),  or  by  employing  a  stetho- 
scope, either  solid  or  flexible,  to  convey  the  sounds  from  the 
chest  wall  to  the  ear  (mediate  auscultation). 


48  DISEASES   OF   THE  LUNGS   AND   PLEURA 

In  England  the  latter  method  is  commonly  employed,  the 
binaural  flexible  stethoscope  being  now  generally  used.  But 
it  should  be  remembered  that  though  this  instrument  pos- 
sesses great  advantages  in  that  it  can  be  used  with  greater 
ease  and  rapidity  than  the  single  stethoscope,  yet  the  latter 
conveys  the  sounds  with  greater  exactness  to  the  ear,  though 
some  of  their  loudness  is  lost  by  their  passage  through  the 
instrument.  In  certain  circumstances  immediate  auscultation 
may  be  preferred,  as  when  in  an  advanced  case  of  emphysema 
the  breath-sounds  are  extremely  weak;  but  the  difficulty  of 
localising  the  exact  spot  auscultated  by  the  unaided  ear  mili- 
tates against  the  more  general  adoption  of  the  method,  which 
nevertheless  is  much  practised  by  certain  French  physicians 
of  distinction.  The  student  should  lose  no  opportunity  of 
familiarising  himself  with  all  three  methods  of  auscultation, 
and  be  ready  to  use  each  as  occasion  may  require. 

Theory  of  Auscultation. — It  is  generally  agreed  that,  with 
the  exception  of  normal  vesicular  inspiration,  all  varieties  of 
breath-sound,  whether  healthy  or  morbid,  are  generated  in 
the  larynx,  and  modified  in  their  transmission  through  the 
different  media  which,  normally  or  abnormally,  intervene 
between  that  organ  and  the  point  of  observation. 

Concerning  the  vesicular  murmur,  there  has  been  much 
diversity  of  opinion.  It  has  been  urged  by  some  that  this 
also  is  nothing  more  than  laryngeal  breathing,  altered  by  its 
transmission  through  layers  of  spongy  and  badly  conducting" 
lung".  Others,  on  the  contrary,  attribute  to  the  inspiratoi-y  por- 
tion a  double  origin,  and  believe  it  to  be  in  part  a  glottic  sound, 
more  or  less  modified  by  conduction,  and  in  part  produced 
within  the  lung  itself  by  the  formation  of  a  "fluid  vein,"  as 
the  air  passes  from  the  terminal  bronchus  into  the  expanded 
infundibula  beyond.  The  latter  view  seems,  on  the  whole,  the 
more  correct,  and  our  knowledge  of  this  subject  may  be 
summed  up  in  the  following"  propositions  : 

I.  The  vesicular  respiratory  murmur  should  be  regarded  as 
a  sound  having  a  double  mechanism,  being  made  up  of  (a)  a 
bruit  produced  by  the  passage  of  air  to  and  fro  through  the 
glottis,  and  reverberated  downwards  through  the  bronchial 
tubes;  (b)  an  infinite  number  of  minor  bruits  similarly  pro- 
duced at  the  openings  of  the  pulmonary  infundibula.     The 


PHYSICAL  EXAMINATION  OF  THE  CHEST  49 

expiratory  portion  of  the  murmur  is  almost  entirely  of  glottic 
mechanism. 

2.  All  other  breath-sounds  are  due  to  the  conduction  of  the 
glottic  bruit  (or  laryngeal  breath-sounds)  above  mentioned, 
through  media  of  different  kinds,  forms  and  densities;  any 
local  currents  of  air  being  only  so  far  operative  inasmuch  as 
they  serve  to  assist  conduction. 

Let  us  now  consider  the  matter  in  greater  detail. 

Vesicular  Murmur — Normal  Breath-Sound. — It  was  origin- 
ally thought,  as  the  name,  indeed,  implies,  that  the  vesicular 
murmur  was  produced  solely  by  the  entry  of  air  into  the  air- 
vesicles  of  the  lung.  Very  soon,  however,  this  view  was 
opposed,  and  in  1834  Beau'  sought  to  prove  that  tracheal, 
vesicular,  bronchial  and  cavernous  breath-sounds  resulted 
from  the  conduction  to  the  surface  of  the  lung  of  a  single 
sound  which  was  produced  in  the  superior  air-passages.  The 
situation  at  which  this  sound  originates  is  no  doubt  the 
glottis,  for  here  the  air  passes  rapidly  backwards  and  forwards 
through  a  small  aperture  into  a  larger  cavity,  giving  rise, 
therefore,  to  a  vibrating  column  of  air,  "  a  fluid  vein,"  and 
the  production  of  a  sound.  This  laryngeal  breath-sound  is 
heard  loudly  in  the  trachea,  and  is  traceable  down  the  bronchi 
as  far  as  they  can  be  followed.  It  is  clear,  therefore,  that  it 
must  enter  at  least  into  the  formation  of  the  vesicular  mur- 
mur. And  that  it  does  so  is  proved  by  the  fact  that  when 
the  larynx  is  much  ulcerated,  and  the  formation  of  a  fluid 
vein  rendered  thereby  more  difficult,  or  when  the  organ  is 
entirely  eliminated,  as  by  an  old  tracheotomy  and  the  perma- 
nent wearing  of  a  tube,  the  vesicular  murmur  over  the  lung 
becomes  extremely  weak.  It  may  be  added,  also,  in  support 
of  the  part  played  by  the  glottis  in  the  origin  of  the  vesicular 
murmur,  that,  as  shown  by  Laennec  and  Beau,  in  animals 
with  long  necks,  such  as  ruminants,  the  respiratory  murmur 
is  much  more  feeble  than  in  carnivora,  though  here,  possibly, 
differences  in  structure  and  functional  activity  come  into  play. 

From  the  above  considerations  there  can  be  no  doubt  that 
the  vesicular  murmur  is  to  a  large  extent  an  altered  glottic 
sound.  Is  it  not,  however,  in  part  at  least,  also  pulmonary, 
produced  by  the  air  being  thrown  into  vibration  as  it  passes 
from  the  minute  terminal  bronchi  into  the  larger  infundibula 
of  the  lung?     The  chief  objection  urged  against  this  view 

4 


5o  DISEASES   OF  THE  LUNGS  AND  PLEURA 

was  the  belief  long  entertained  that  the  tidal  air  did  not  pass 
beyond  the  finest  bronchi,  and  consequently  that  the  currents 
of  air  drawn  at  each  inspiration  into  the  infundibula,  in 
obedience  to  their  enlargement  with  the  expansion  of  the  chest, 
must  be  so  slight  and  of  so  low  a  velocity,  as  to  be  incapable 
of  generating  a  fluid  vein  and  the  production  of  a  sound, 
though  the  necessary  physical  conditions  are  actually  present. 
When  we  consider,  however,  the  number  of  infundibula  pre- 
sent in  the  lung  (the  alveoli  have  been  estimated  by  the  late 
Professor  MacAHster  at  355,000,000),  it  is  evident  that  the  in- 
finite repetition  of  even  the  very  faintest  sound  must  become 
important,  and  materially  contribute  to  the  respiratory 
murmur.  Further,  it  was  pointed  out  by  the  late  Dr.  Wash- 
bourne,^  in  his  Croonian  Lectures,  that  it  had  been  demon- 
strated that  the  upper  air-passages  and  the  ramifications  of  the 
bronchial  tree  possess  a  capacity  of  only  140  c.c.  and  can  there- 
fore only  accommodate  about  one-third  of  the  500  c.c.  of  air 
inhaled.  The  remainder  of  the  tidal  air  must,  therefore,  directly 
enter  the  infundibula,  and,  the  conditions  necessary  for  the 
formation  of  a  fluid  vein  being  present,  a  murmur  should 
arise. 

That  some  portion  of  the  vesicular  murmur  is  actually  pro- 
duced in  this  way  is  strongly  supported  by  the  observations 
of  Bondet  and  Chauveau,*  which  have  never  been  contra- 
dicted, as  well  as  by  the  experiments  of  Dr.  J.  F.  Bullar.' 
The  former  observers  experimented  upon  a  horse  suffering 
from  pneumonia,  which  affected  the  lower  half  of  the  left 
lung.  On  auscultating  the  animal,  exaggerated  breathing 
Avas  heard  over  the  right  lung  and  over  the  upper  half  of  the 
left,  tubular  breath-sound  being  distinct  over  the  lower  or 
affected  half  of  the  left  lung.  These  preliminary  observations 
made,  the  trachea  was  opened  by  an  incision  twenty  centi- 
metres in  length,  and  the  following  phenomena  were 
noted : 

1.  On  auscultation  over  the  trachea  below  the  incision,  the 
wound  being  held  widely  open,  the  inspiratory  bruit  was 
almost  completely  lost,  and  the  expiratory  sound  but  faintly 
audible^ 

2.  On  auscultation  over  the  consolidated  lung,  whilst  the 
wound  in  the  trachea  was  held  widely  open,  no  tubulor  sound 
could  be  heard  during  inspiration,  and  only  a  faint,  brief,  and 


PHYSICAL  EXAMINATION   OF  THE  CHEST  5I 

abortive  sound  during  expiration.  Over  the  rest  of  the  lung 
and  over  the  opposite  (sound)  lung,  however,  the  normal 
respiratory  sounds  were  clearly  heard. 

It  should  be  added  that  a  musical  reed  was  introduced  into 
the  trachea,  and  that  the  artificial  voice-sound  so  produced, 
though  inaudible  over  the  healthy  lung,  was  heard  distinctly 
over  the  consoHdated  area,  thus  proving  that  a  possible  source 
of  fallacy — viz.,  the  blocking  of  the  left  lower  bronchus  by 
blood-clot — did  not  exist. 

It  would  seem,  therefore,  from  these  considerations,  that 
the  pulmonary  element  does  take  an  important  share  in  the 
production  of  the  normal  respiratory  sound,  and  is,  indeed, 
the  cause  of  its  characteristic  quality. 

Abnormal  Breath-Sounds. — IVeakness  of  breath-sound  may 
simply  arise  from  feebleness  of  the  muscular  chest  move- 
ments. Often,  however,  it  is  the  result  of  disease,  and  is 
perhaps  best  observed  when  a  small  pleural  effusion  partially 
compresses  the  lung.  In  emphysema,  also,  when  the  expan- 
sion of  the  lung  is  impaired  owing  to  the  over-distension  and 
atrophy  of  its  tissue,  which  characterises  the  disease,  the 
respiratory  sounds  are  weakened. 

Suppression  of  Breath-Sounds. — When  a  lung  is  separated 
from  the  surface,  and  compressed  by  a  sufficient  layer  of  fluid, 
or  has  its  bronchus  occluded  from  any  cause,  suppression  of 
the  breath-sounds  follows.  Even  in  cases  of  considerable 
effusion,  however,  a  certain  amount  of  breath-sound  is  heard 
over  the  upper  part  of  the  chest,  the  fluid  naturally  gravitating 
to  the  lower  portion  of  the  thorax,  so  that  the  upper  area  of 
the  lung  escapes  compression.  When  the  lung  is  separated 
from  the  thoracic  wall  by  thickened  adhesions,  and,  as  is 
usually  the  case,  is  indurated  and  collapsed,  the  breath-sound 
is  partially  suppressed,  the  glottic  bruits  being  only  very  im- 
perfectly conducted. 

Exaggerated  Breathing. — This  is  heard  in  the  healthy  child. 
More  rapid  breathing,  more  rapid  passage  of  air  through  the 
glottis  and  into  the  lungs,  and  greater  thinness  of  the  chest 
walls,  are  the  conditions  upon  which  this  enhanced  breath- 
sound  depends.  The  expiration  is  generally  rather  prolonged, 
and  both  sounds  are  coarser  than  ordinary.  Exaggerated 
breath-sound  is  usually,  in  health,  limited  to  children  of  tender 
years,  and  hence  its  synonym  "  puerile  breathing,"  but  some 


52  DISEASES   OF  THE  LUNGS   AND   PLEURA 

persons  preserve  this  quality  through  adult  life.  This  variety 
of  breathing  is  heard  over  the  sound  side  in  cases  in  which 
the  respiratory  function  of  one  lung  is  in  abeyance  from  any 
cause.  It  may  be  similarly  heard  over  one  portion  of  a  lung, 
the  remainder  of  which  is  diseased.  Hence  another  synonym, 
"  compensatory  breathing."  It  indicates  respiratory  vigour, 
and  is  so  far  of  good  augury,  inasmuch  as  it  shows  that  an 
enlarged  lung,  or  portion  of  a  lung,  is  not  merely  dilated,  but 
also  functionally  more  active — a  most  important  fact  to  ascer- 
tain in  cases  of  one-sided  chest  disease. 

Jerking,    Wavy    and    Cogged    Breathing    ("cog-wheeled 
respiration ")  are  varieties  to  which  different  authors  have 
attached    very    different    importance.      In    jerking    or    wavy 
breathing   the    inspiration,    instead    of    being   a   continuous 
sound,  is  two  or  three  times  interrupted.     The  expiration  is 
rarely  affected  in  this  way,  and  may  be  normal,  or  simply 
harsh  and  somewhat  prolonged.     One  so  frequently  meets 
with  jerking  respiration  in  nervous  people  that,  when  un- 
accompanied by  other  morbid  sounds,  but  little  importance 
should  be  attached  to  it.     The  following  are   some  of  the 
commoner  abnormal  conditions  under  which  it  may  occur : 
(i)   It  may  be   due   to   irregular   action   of   the   respiratory 
muscles  under  conditions  of  pain,  as  in  pleurodynia,  pleurisy, 
and  myalgia.     (2)  It  may  be  the  result  of  hysteria  and  other 
nerve  disorders.     (3)  It  may  be  produced  (mostly  on  the  left 
side)  by  cardiac  pulsation,  its  rhythm  being  then  synchronous 
with  that  of  the  heart.  (4)  In  certain  cases  it  may  be  accounted 
for  by  textural  diseases  of  the  lung  itself,  or  by  pleural  adhe- 
sions, which  lead  to  a  want  of  uniformity  in  pulmonary  elas- 
ticity and  expansile  power.     For  this  reason  it  may  sometimes 
be  met  with  in  phthisis  at  quite  an  early  stage  of  the  disease, 
A   remarkable   instance   of   wavy   cavernous   breathing   was 
observed  by  one  of  us  in  a  case  in  which  the  entering  bron- 
chus to  a  large  cavity  was  partially  occluded  by  a  small  pul- 
monary aneurism  projecting  into  its  lumen  close  to  the  cavity, 
and  thus  alternately  stopping  and  permitting  the  cavernous 
sound.     The  death  of  the  patient  from  sudden  haemoptysis,  a 
few  hours  later,  verified  and  explained  the  observation.'" 

Prolonged  Expiration. — Prolongation  of  expiration  is  per- 
haps the  most  important,  as  it  certainly  is  the  earliest  of  the 
signs  of  commencing  consolidation  of  the  lung.     It  marks 


PHYSICAL   EXAMINATION   OF  THE   CHEST  ,53 

the  transition  between  vesicular  and  bronchial  breath-sound, 
and  it  indicates  that  over  a  certain  extent  of  lung  the  factors, 
which  normally  lead  to  the  production  of  the  vesicular  sound, 
are  partially,  at  least,  in  abeyance,  tending  therefore  to  the 
predominance  of  the  unaltered  glottic  sounds,  with  their  dis- 
tinctive characters  and  proportion.  Thus,  with  prolongation 
of  the  expiration  are  associated  other  characteristics  of  the 
glottic  element.  For  example,  division  between  inspiration 
and  expiration  (divided  respiration)  may  be  often  noticed; 
and  as  the  expiration  becomes  more  prolonged,  equalling,  or 
even  slightly  exceeding,  the  inspiration,  the  vesicular  quality 
of  the  breath-sounds  gradually  disappears,  the  breathing 
acquiring  at  first  a  harsh,  and  later  a  true  bronchial  character. 
Indeed,  all  stages  between  simple  prolongation  of  the  expira- 
tion and  true  bronchial  breathing,  in  which  the  glottic  sounds 
are  conducted  in  all  their  intensity,  may  be  observed.  To 
certain  of  these  intermediate  stages  the  terms  "harsh," 
"vesiculo-bronchial,"  "transitional,"  or  "indeterminate,"  have 
been  applied. 

Bronchial  Respiration. — This  variety  of  respiratory  murmur 
is  heard  normally  at  the  lower  part  of  the  trachea,  and  in  less 
degree  in  the  first  intercostal  space  for  a  short  distance  on 
either  side  of  the  sternum.  In  many  subjects,  especially,  as 
Laennec  pointed  out,  those  who  are  very  thin,  it  may  be  heard 
over  the  interscapular  regions,  from  the  last  cervical  vertebra 
to  the  level  of  the  third  or  fourth  dorsal,  owing  to  the 
proximity  of  the  trachea  and  large  bronchi  in  this  region. 
As  a  morbid  sign  it  is  heard  in  its  most  characteristic  form 
over  a  lung  consolidated  by  acute  pneumonia.  Bronchial 
breath-sound  possesses  a  peculiar  penetrating  and  blowing 
character,  and,  as  Skoda  pointed  out,  can  best  be  imitated  by 
placing  the  tongue  in  the  position  to  form  the  consonant 
"ch"  (hard  x),  and  drawing  the  breath  to  and  fro.  It  differs, 
also,  from  vesicular  breathing  in  that  expiration  is  often  as 
loud  and  long  as  inspiration,  and  that  the  two  stages  of 
respiration  are  separated  from  each  other  by  a  perceptible 
pause.  It  varies  in  intensity  according  to  the  degree  of  con- 
solidation and  the  permeabiHty  of  the  bronchial  channels. 

Laennec  was  of  opinion  that  the  sounds  originated  in  the 
affected  lung,  but  it  is  now  admitted  that  they  are  in  reality 
generated  in  the  larynx,  and  thence  conducted  down  the  air- 


54.  DISEASES   OF   THE  LUNGS   AND   PLEUSLE 

passages  into  the  chest,  and  so  to  the  observer's  ear.    The 
following  are  the  reasons  for  this  beUef  : 

1.  The  breath-sounds  heard  over  the  larynx,  and  produced 
there,  possess  all  the  characteristics  of  bronchial  breathing, 
and  differ  from  the  latter  chiefly  in  their  greater  intensity. 

2.  In  pneumonia,  in  which  this  form  of  breathing  is  espe- 
cially heard,  the  lung  is  impacted  by  a  coagulated  substance 
which  fills  it,  and  maintains  it  in  the  state  of  permanent 
inspiration,  a  condition  which  forbids  the  entry  of  air.  The 
formation,  therefore,  of  a  fluid  vein  and  the  production  of  a 
sound  within  the  .affected  lung  is,  under  these  circumstances, 
impossible. 

3.  The  experiment  of  Bondet  and  Chauveau  upon  the 
hepatised  lung  of  the  horse,  to  which  we  have  already  referred, 
points  strongly  in  the  same  direction.  These  observers,  on 
holding  widely  open  the  wound  in  the  trachea,  caused  the 
respiratory  bruit  heard  over  the  hepatised  lung  to  disappear, 
whilst  over  the  sound  lung  the  respiratory  murmur  was 
scarcely  at  all  modified. 

It  would  appear,  then,  that  the  two  conditions  for  the  pro- 
duction of  bronchial  breath-sound  are  consolidation  of  lung 
and  patency  of  bronchi.  Any  obstruction  of  the  main  bron- 
chus will  obscure  the  sound,  and,  we  may  add,  separation  of 
the  consolidated  lung  from  the  parietes,  whether  by  fluid  or 
thickened  pleura,  will  render  it  less  distinct.  In  some  rare 
cases  of  pneumonia  the  breathing  is  suppressed  owing  to  the 
exudation  overflowing  from  the  alveoli  into  the  small  bronchi, 
and  thus  occluding  them.  Bronchial  breath-sound  may  be 
produced  by  other  than  diseases  of  the  lung.  A  mediastinal 
tumour,  whether  aneurismal  or  cancerous,  situated  between 
the  thoracic  wall  and  a  bronchus,  will  yield  the  sound,  the 
vibrations  within  the  tube  being  conveyed  through  the  sub- 
stance of  the  tumour  almost  unaltered  to  the  chest  wall. 

By  many  writers  the  term  tubular  is  used  as  synonymous 
with  bronchial,  tubular  and  bronchial  breathing  being  thus 
interchangeable  names.  .Some,  however,  restrict  the  term 
"tubular"  to  that  variety  of  bronchial  breathing  which  is 
high-pitched  and  whiffing  in  character,  such  as  is  often  heard 
over  a  pulmonary  cavity. 

Laryngeal  and  Tracheal  Breathing,  heard  on  auscultation 
over  the  larynx  and  trachea  respectively,  possess  in  a  marked 


PHYSICAL  EXAMINATION   OF   THE  CHEST  55 

degree,  as  Laennec  pointed  out,  the  characteristics  of  bron- 
chial breathing,  and  differ  only  in  the  greater  loudness  and 
intensity  of  the  sounds. 

Cavernous  Breath-Sound. — This  consists  of  a  hollow 
inspiratory  and  expiratory  sound,  which  has  been  compared 
to  the  sound  produced  by  blowing-  into  the  cavity  formed  by 
the  two  hands.  The  expiration  must  especially  be  attended 
to  in  listening'  for  this  variety  of  breath-sound;  it  is  wavering, 
hollow,  and  prolong'ed.  We  agree  with  the  late  Dr.  Austin 
Flint  in  attaching-  importance  to  the  fact  that  the  expiration 
is  of  lower  pitch  than  the  inspiration,  as  serving  to  distin- 
guish cavernous  respiration  from  bronchial,  in  which  the 
inspiratory  and  expiratory  are  of  similar  pitch.  Cavernous 
breathing  is  heard  over  pulmonary  cavities,  which  are  of  a 
certain  size  (larger  than  a  filbert),  which  are  in  part  at  least 
empty,  and  which  communicate  freely  with  one  or  more 
bronchi. 

As  to  the  mechanism  of  this  sound,  it  cannot  be  denied  that 
it  may  be  imitated  by  breathing-  into  the  hollow  of  the  two 
hands,  a  fact  which  suggests  that  within  the  chest  it  may  be 
produced  by  the  air  entering  and  leaving  a  large  cavity.  But 
it  may  be  stated  at  once  that  in  general  this  is  not  the  case. 
Cavernous  breathing  is  nothing  more  than  bronchial  breath- 
ing modified  by  the  resonating-  properties  of  a  large  cavity; 
but  though  the  vibrations  which  produce  it  must  pass  from 
the  bronchus  to  the  cavity,  to  be  there  modified  and  acquire 
that  reverberating-,  "  cavernous  "  quality  which  distinguishes 
this  form  of  breathing",  it  is  not  necessary  for  the  air  itself  to 
enter,  nor,  indeed,  would  this  be  always  possible,  owing  to  the 
unyielding  character  of  the  cavity  walls.  That  the  sound  is 
not  dependent  upon  such  entry  is  further  supported  by  the 
fact  that  the  cavernous  quality  is  heard  very  loudly  during 
expiration,  whereas  the  expulsion  of  air  from  a  cavity  could 
not  give  rise  to  the  formation  of  a  "fluid  vein"  and  the  pro- 
duction of  a  sound.  In  short,  cavernous  breathing  is  pro- 
duced by  the  conduction  of  the  laryngeal  vibrations  into  a 
cavity,  and  their  consequent  modification,  the  entry  of  air 
into  the  cavity  not  being  an  essential  factor  in  the  process. 

Amphoric  Breathing. — This  is  really  a  variety  of  cavernous 
breathing,  the  cavity  being-  large,  superficial  and  thin-walled. 
It  may  be  imitated  by  breathing  into  a  large  jar  or  amphora, 


56  DISEASES   OF   THE  LUNGS   AND   PLEUR/E 

whence  the  derivation  of  the  name.  In  cases  of  pneumo- 
thorax in  which  the  opening  is  free,  this  form  of  breath-sound 
is  heard  to  perfection,  but,  as  with  cavernous  breathing,  pene- 
tration of  the  air  into  the  cavity  is  not  essential  (Gee).^* 

Adventitious  Sounds. — With  regard  to  the  various  adven- 
titious sounds  heard  within  the  chest,  we  have  based  our 
classification  upon  that  originally  suggested  by  Laennec, 
The  term  "  rale  "  is  thus  retained  as  a  general  name  to  include 
the  numerous  added  sounds  which  in  disease  are  produced 
within  the  air-passages  and  lungs  by  the  act  of  respiration. 

Of  rales  there  are  three  chief  varieties : 

1.  The  dry  rale,  with  its  subdivisions,  rhonchus  and  sibilus. 

2.  The  moist  or  liquid  rale — "  mucous  rale  "  of  Laennec — 
with  its  subdivisions,  bubbling,  crackling,  gurgling  and 
cavernous  rale. 

3.  The  fine-hair  crepitation. 

In  listening  for  these  adventitious  sounds,  our  attention 
will  be  attracted  mainly  to  the  inspiratory  portion  of  the 
respiratory  act,  during  which  they  are  as  a  rule  best  heard, 
whilst  modified  breath-sounds  are  most  characteristically 
heard  during  expiration. 

Concerning  the  mode  of  formation  of  these  sounds,  some 
are  simple,  and  require  but  little  explanatory  comment, 
Rhonchi  and  sihili  are  but  musical  notes  of  higher  or  lower 
pitch,  depending  upon  vibrations  of  air  set  up  in  tubes  par- 
tially obstructed  by  local  thickenings  of  their  lining  mem- 
branes, by  mucous  collections  or  pellets  adhering  to  their 
sides  so  as  partially  to  obstruct  them,  or,  finally,  by  spasmodic 
narrowing-  of  the  tubes  themselves.  It  will  be  observed  that 
all  these  causes  of  sibilant  and  sonorous  rales  within  the 
chest  are  of  a  temporary  or  transient  nature,  and  accordingly 
these  sounds  are  very  inconstant,  appearing  and  disappear- 
ing, or  shifting  from  one  spot  to  another,  even  whilst  the 
patient  is  under  examination.  Thus,  a  vigorous  cough,  clear- 
ing the  tubes  of  mucous  collection,  will  often  for  a  time 
remove  a  sonorous  rhonchus,  while  the  sibilant  sounds  in 
asthma,  or  bronchitis  with  spasm,  will  be  partially  or  wholly 
removed  by  the  inhalation  of  chloroform  or  ether.  It  must 
further  be  noted  that  in  all  cases  the  true  respiratory  murmur 
is  obscured  and  enfeebled  by  the  presence  of  these  rhonchi, 
to  return  on  their  removal;  and  it  is  a  matter  of  great  impor- 


PHYSICAL   EXAMINATION   OF   THE   CHEST  5/ 

tance  in  practical  auscultation  to  observe  whether  the  respira- 
tory murmur  is  altogether  thus  obscured,  or  whether  the  air 
penetrates  more  or  less  through  the  rales  into  the  vesicular 
tissue. 

Stridor  is  a  variety  of  rhonchus  in  which  the  vibrations  are 
very  coarse,  and  the  sound  produced  rough  and  low- 
pitched.  It  is  best  heard  during  inspiration.  It  may  be  occa- 
sioned by  some  paralytic  affection  of  the  glottis,  which  pre- 
vents the  cords  from  being  drawn  apart  during  inspiration, 
and  allows  them  partially  to  flap  together,  and  thus  to  vibrate. 
It  is  in  other  cases  produced  by  the  pressure  of  a  tumour 
directly  upon  the  trachea  or  a  main  bronchus.  The  vibra- 
tions which  produce  stridor,  and  those  of  the  stronger  forms 
of  rhonchus,  are  so  coarse  as  to  be  perceptible  to  the  hand 
applied  to  the  surface  of  the  chest,  thus  producing  rhonchal 
fremitus. 

Liquid  or  Moist  Rale. — This  variety  of  rale,  described  by 
Laennec  under  the  heading  "  Mucous  Rak,"  is  produced,  as 
he  pointed  out,  by  the  bubbling  of  air  through  fluid,  of  what- 
ever nature,  contained  either  in  the  bronchi  or  in  cavities  in 
the  lung.  The  sound  may  be  exactly  imitated  by  blowing 
into  soapy  water  with  a  pipe  or  straw.  These  rales  differ  in 
character  according  to  the  bubbles  which  produce  them,  and 
were  accordingly  classified  by  their  discoverer  into  "  large," 
"  medium,"  and  "  small."  They  are  much  modified  also  by 
the  condition  of  the  surrounding  lung.  Thus,  if  the  air- 
vesicles  around  are  healthy,  as  in  bronchitis,  they  have  a 
"bubbling"  quality.  If,  on  the  other  hand,  there  is  more  or 
less  consolidation,  they  acquire  a  more  sharply  defined  char- 
acter, and  are  spoken  of  as  "crackling"  rales.  If,  again, 
they  are  formed  in  connection  with  a  cavity,  they  become 
echoing  and  reverberating,  and  are  termed  "  gurgling "  or 
"  cavernous." 

The  Crackling  Rale,  "  humid  crackling,"  "  humid  clicking," 
or  "sharp  crepitation,"  is  significant  of  fluid  in  the  tubes, 
together  with  the  presence  of  more  or  less  consolidation  in 
the  surrounding  lung.  This  rale  is  heard  in  broncho-pneu- 
monia, and  very  frequently  in  the  softening  stages  of  phthisis, 
in  which  the  bronchial  tubes  are  filled  with  liquid  debris  from 
the  softening  foci,  and  are  themselves  surrounded  by  patches 
of   solid   lung.     In   character   it   is   a   sharply-defined,   moist 


58  DISEASES   OF   THE  LUNGS   AND   PLEURA 

sound,  consisting  of  two  or  three  inspiratory  and  one  or  two 
expiratory  elements,  the  respiratory  murmur  being  itself 
often  masked  or  replaced  by  the  crackles.  The  sound  varies 
much  in  sharpness  of  definition,  according  to  the  condition 
of  the  pulmonary  tissue.  If  this  be  in  a  state  of  massive 
tuberculous  consolidation,  as  in  the  most  acute  form  of 
phthisis,  the  clicks  are  strongly  conducted,  and  metallic  in 
character.  In  other  cases,  when  the  softening  nodules  are 
more  widely  separated  by  spongy  and  tolerably  healthy  lung 
tissue,  the  crackles  are  muffled  and  more  or  less  obscured. 
Over  portions  of  lung  which  are  functionally  inactive  under 
ordinary  circumstances  of  respiration,  owing  to  fibroid  change 
or  pleural  thickening,  no  moist  sounds  may  be  heard  when 
softening  takes  place  until  a  sharp  cough  has  forced  air  into 
the  tissues  and  produced  them.  This  is  a  most  important 
point  to  remember  in  auscultation. 

Cavernous  Rale — Gurgling  Rale. — This  is  nothing  but  a 
crackling  rale  of  large  size,  and  of  a  loud,  reverberating 
quality.  Bubbles  bursting-  in  a  cavity  will  no  doubt  account 
for  the  formation  of  such  sounds,  as  we  may  perceive  on 
listening  over  a  secreting  cavity  whilst  the  patient  coughs, 
when  we  hear  the  splashing'  and  gurgiing  sounds  resulting 
from  the  forcible  commingling  of  air  and  fluid.  But  in  large 
and  comparatively  dry  cavities  we  can  hardly  imagine  any 
such  commingling  to  take  place  during-  ordinary  or  deep 
breathing,  even  supposing  that  air  passes  backwards  and  for- 
wards into  the  cavity  with  any  appreciable  current,  which  is 
not  necessarily  the  case.  In  truth  entry  of  air  into  the  cavity 
is  not  essential  to  produce  the  sound,  since  any  moist  rales 
in  the  associated  bronchi  will  be  heard  with  exaggerated 
intensity  over  the  cavity,  and  in  this  way  no  doubt  many 
gurgling  or  cavernous  rales  are  produced. 

Should  the  cavity  be  of  sufficient  dimensions,  and  the 
rale  very  fine,  it  may  then  take  on  special  characteristics,  and 
acquire  the  qualities  of  metallic  tinkling,  a  sound  aptly  com- 
pared by  Laennec  to  that  produced  by  striking  a  metal  vessel 
with  a  pin.  It  is  entirely  erroneous  to  suppose — as  may  be 
demonstrated  frequently  on  post-mortem  inspections— that 
this  variety  of  rale  is  significant  of  pneumothorax  only;  it 
may  be  well  heard  over  a  large  cavity,  and  its  mechanism  is 
probably  the  same  in  both  instances — viz.,  the  reverberation 


PHYSICAL   EXAMINATION    OF   THE   CHEST  59 

through  a  large,  thin-walled,  and  empty  cavity  of  a  very  fine 
moist  rale  produced  in  the  bronchus  or  fistulous  channel  lead- 
ing to  the  cavity. 

Fine-Hair  Crepitation. — Great  difference  of  opinion  has 
prevailed  respecting  the  nature  and  mechanism  of  this  variety 
of  rale.  All  observers  agree  that  it  is  best  heard  in  the  first 
stage  of  pneumonia,  and  some  regard  it  as  the  pathogno- 
monic sign  of  that  disease.  This  sound  may  be  defined  as 
composed  of  a  variable,  sometimes  immense,  number  of  sharp 
crackling-  sounds  of  minute  size,  all  perfectly  similar  to  each 
other,  and  rapidly  evolved  in  puffs  more  or  less  prolonged. 
The  sounds  are  dry  in  quality,  and  coexist  exclusively,  except 
in  rare  cases,  with  inspiration,  and,  once  established,  remain 
persistent  until  superseded  by  other  phenomena.  The  late 
Dr.  C.  J.  B.  Williams's  description  of  the  sound,  as  resem- 
bling that  produced  by  slowly  and  firmly  rubbing  a  lock  of 
hair  between  the  finger  and  thumb  close  to  the  ear,  has  been 
generally  accepted. 

The  fine-hair  crepitation  may,  however,  occur  in  conditions 
other  than  pneumonia.  Thus  it  may  be  heard  in  healthy 
chests,  when  we  auscultate  the  bases  of  the  lungs  of  those 
who  have  been  confined  to  bed,  and  instruct  them  to  take  a 
deep  breath,  thereby  opening  up  alveoli  which  have  been  for 
a  time  disused.  In  disease  it  may  occur  in  cases  of  pul- 
monary collapse,  in  certain  degrees  of  pulmonary  oedema  and 
in  the  first  stage  of  pulmonary  apoplexy;  although  it  must 
be  confessed  that  in  these  conditions  the  sound  does  not  pos- 
sess that  sharpness  which  characterises  it  in  pneumonia,  and 
which  is  attributable  to  the  increasing  density  of  the  sur- 
rounding lung.  Whereas  in  pneumonia  the  sound  is  accom- 
panied by  bronchial  breathing,  in  other  conditions  it  is  as  a 
rule  unattended  by  any  breath-sound.  The  sound  is  appar- 
ently produced  by  the  separation  of  sticky  aveolar  walls 
which  have  previously  been  in  contact,  and  in  pneumonia  the 
actual  state  of  the  lung  which  gives  rise  to  it  may  be  assumed 
to  be  one  of  cedematous  exudation  from  inflammatory  con- 
gestion. When  the  exudation  into  the  air  cells  is  complete 
and  consolidated,  the  crepitation  ceases. 

A  reference  may  be  made  to  one  other  variety  of  rale 
described  by  Laennec,  the  Dry  Crackle,  "  craquement  ou 
rale  crepitant  sec  a  grosses  bulles."    This  was  believed  by 


6o  DISEASES   OF   THE   LUNGS   AND   PLEURA 

him  to  have  a  special  character,  and  to  be  pathognomonic  of 
emphysema.  In  this  view  he  has  not  been  confirmed  by  later 
observers.  The  term  has  long  been  in  use  at  the  Brompton 
Hospital  as  descriptive  of  the  few  inspiratory  crackles 
regarded  as  significant  of  commencing  tuberculous  softening. 

Pleural  Friction. — This  sound  has  been  known  from  the 
earliest  times,  having  been  described  by  the  Hippocratic 
writers,  who  compared  it  to  "the  grating  or  creaking  of  a 
leather  thong."*  Curiously  enough  its  significance  was  mis- 
understood by  Laennec,  who  believed  the  "bruit  de  frotte- 
ment  ascendant  et  descendant,"  as  he  termed  it,  to  be  the 
result  of  intralobular  emphysema.^'  Its  true  relation  to 
pleurisy  was  demonstrated  a  few  years  later  by  Reynaud.'- 

Friction  is  produced  by  roughening  and  inequalities  of  the 
pleural  surfaces,  so  that  the  two  layers  no  longer  g'lide 
smoothly  upon  each  other.  It  is  well  heard,  therefore,  in 
the  early  stages  of  pleurisy,  when  the  pleurae  are  roughened, 
but  still  in  contact.  The  sound  may  occur  over  any  area 
of  the  chest,  but  is  best  heard  over  the  lower  portions,  since 
here  the  movements  of  the  pleural  surfaces  are  most  exten- 
sive, owing  to  their  proximity  to  the  diaphragm.  In  character 
the  sound  may  resemble  the  creaking-  of  a  piece  of  leather, 
dry  friction^  or  it  may  be  softer  in  character  and  more  like  a 
moist  rale,  the  term  moist  friction  being  then  appHed  to  it. 
Friction  may  accompany  both  inspiration  and  expiration,  and 
it  is  usually  best  heard  at  the  end  of  inspiration  and  the  com- 
mencement of  expiration.  If  the  pleura  in  contact  with  the 
heart  be  inflamed,  the  sound  may  be  synchronous  with  the 
beat  of  the  heart,  and  suggest  pericarditis.  Pleuro-pericardial 
friction,  however,  as  the  sound  is  then  termed,  may  be  dis- 
tinguished from  true  pericardial  friction  by  the  influence  upon 
it  of  the  respiratory  movements,  a  deep  inspiration  or  a  deep 
expiration  materially  modifying  the  sound. 

Yoice-Sounds. — Enough  has  been  said  in  the  earlier  part  of 
this  chapter  respecting  the  mechanism  of  breath-sounds  to 
make  it  clear  that  there  can  be  no  good  reason  for  any 
mystery  as  to  the  way  in  which  voice-sounds  are  produced, 

*  "  If  the  lung  falls  against  the  side,  the  patient  coughs  ...  a  heavy 
weight  seems  to  exist  in  the  chest,  and  sharp  pains  sting  him ;  and  it 
grates  like  a  leather  thong,  and  stops  the  breath"  (Hippocrates,  "  De 
Morbis,"  ii.,  §  59). 


PHYSICAL  EXAMINATION   OF  THE  CHEST  6l 

or  in  which  they  are  intensified  or  annulled  under  different 
morbid  conditions  of  the  lungs  and  pleurae.  There  can  be 
no  doubt  that  they  are  produced  in  the  larynx,  and  conducted 
thence  downwards  through  the  bronchial  tubes.  These  chan- 
nels in  the  normal  state  are  held  patent  by  the  elastic  traction 
upon  them  of  the  surrounding  lung,  and  they  serve,  there- 
fore, as  so  many  speaking-tubes,  although  the  direction  of  the 
current  of  air  during  articulation  is  not  favourable  to  the  best 
possible  conduction.  The  rapid  subdividing  of  the  tube  and 
the  embedding  of  the  branches  in  an  ill-conducting  material 
is,  moreover,  highly  unfavourable  to  conduction  of  sound, 
and  were  it  not  for  the  shortness  of  distance,  the  voice-sounds 
would  not  be  audible  at  all.  As  it  is  they  are  conducted  to 
the  ear  in  a  muffled  manner,  and  to  the  buzzing  sound  so 
produced  the  term  normal  vocal  resonance  is  applied. 

If  the  glottis  be  destroyed  by  tuberculous  or  syphilitic 
disease,  the  voice-sound  is,  of  course,  annulled,  and  even  the 
whisper  sound  is  impaired,  showing  that  the  •glottis  is  also 
concerned  in  its  production.  If  the  main  bronchus  on  one 
side  be  compressed  or  occluded,  the  voice-sounds  are  annulled 
on  that  side,  and  vocal  vibrations,  which  are  merely  palpable 
sounds,  are  similarly  obscured.  A  like  result  also  follows  if 
the  pleura  be  filled  with  fluid,  or  the  chest  walls  be  very  fat, 
both  conditions  actings  as  a  barrier  to  the  transmission  of  the 
vibrations.  If,  on  the  other  hand,  the  termination  of  the 
tubes  be  surrounded  by  a  better  conducting  material,  as  in 
pneumonia,  the  sounds  will  be  conducted  to  the  surface  of 
the  chest  with  their  laryngeal  qualities  but  little  altered,  and 
they  will  be  heard  loudly  and  clearly  as  though  one  were 
listening  directly  over  a  bronchus.  Bronchophony,  in  short, 
will  be  produced.  If,  again,  a  large  bronchus,  instead  of 
being  subdivided  into  innumerable  smaller  and  diminishing 
branches,  abruptly  terminates  in  an  empty  cavity  occupying 
the  area  of  its  former  distribution,  then  the  voice  and  whisper 
sounds  transmitted  downwards  will  be  no  longer  muffled  by 
the  normal  lung  tissue,  but  will  be  loudly  heard  over  the 
region  of  the  cavity,  giving  rise  to  bronchophony  and  whis- 
pering pectoriloquy. 

In  certain  cases  of  pleural  effusion,  and  sometimes  in  pneu- 
monia, the  bronchophony  has  a  high-pitched,  nasal  and  trem- 
ulous character,  and  is  then  spoken  of  as  cugophony.    The 


62  DISEASES   OF  THE  LUNGS   AND   PLEURA 

late  Dr.  Stone  advanced  the  view,  which  has  since  been  gen- 
erally accepted,  that  the  peculiar  character  of  this  voice-sound 
is  to  be  ascribed  to  the  suppression  or  partial  suppression  of 
the  fundamental  tones,  and  the  accentuation  of  the  higher 
overtones  or  harmonics.  He  further  believed  that  for  this 
change  to  take  effect  the  presence  of  fluid  is  essential,  the 
slower  vibrations  being  unable  to  penetrate  the  Hquid,  while 
the  more  rapid  vibrations  of  the  higher  notes  are  transmitted. 

This  view,  in  so  far  as  it  presupposes  the  presence  of  fluid, 
has  been  disputed  on  experimental  grounds  by  Sir  Frederick 
Taylor,"  who  suggests  that  in  all  cases  the  change  is  pro- 
duced by  the  compression  of  the  hronchial  tubes,  whether  by 
fluid  or  by  some  exudation  into  the  alveoli,  so  that  their  shape 
becomes  altered,  and  whereas  normally  they  resonate  the  lower 
harmonics,  now  they  can  resonate  only  the  higher  ones.  The 
tremulous,  bleating  character  of  the  sound  he  would  regard 
as  simply  the  result  of  discord  produced  by  the  presence  of 
"  beats  "  occurring  between  the  higher  harmonics  thus  rein- 
forced. The  hypothesis  is  an  interesting  one,  especially  as  it 
attempts  to  explain  what  is  undoubtedly  a  fact — namely,  the 
not  uncommon  occurrence  of  segophony  in  cases  of  pneu- 
monia, quite  apart  from  any  effusion  into  the  pleural  cavity. 
It  is  to  be  remarked,  however,  that  in  cases  of  moderate  effu- 
sion, in  which  the  aegophony  is  heard  to  perfection,  the 
bronchial  tubes  are  not  compressed,  as  we  have  elsewhere 
pointed  out. 

Amphoric  or  metallic  echo  is  a  voice-sound  which  is  often 
heard  in  cases  of  pneumothorax.  It  is  probably  to  be 
regarded  as  a  reflected  sound,  due  to  the  impingement  of 
vibrations  against  the  walls  of  a  large  echoing  cavity.  It  is 
best  heard  in  cases  in  which  the  communication  with  the 
pleura  is  very  small. 

Auscultatory  Percussion.— T/i^  Bell  Sound,  or  hndt  d'airain, 
is  a  physical  sign  which  we  really  owe  to  Trousseau,'*  though 
it  is  probable  that  Laennec  was  to  some  extent  cognisant  of 
it.  It  is  elicited  by  auscultation  over  a  large  cavity  containing 
air,  while  an  assistant  percusses  with  two  coins  over  the  same 
region.  The  ringing  sound  thus  produced  differs  markedly 
from  the  dull  thud  which  alone  is  heard  over  the  adjacent 
lung.  In  cases  of  pneumothorax  the  bell  sound  is  often 
heard  to  perfection;  but  it  may  also  be  heard   over  large, 


PHYSICAL  EXAMINATION   OF  THE  CHEST  63 

smooth-walled,  pulmonary  cavities,  or  a  distended  stomach. 
Subphrenic  abscesses  or  hydatids  with  decomposing  and 
gaseous  contents  may  also  give  rise  to  it. 

The  peculiarly  ringing  and  musical  quality  of  the  sound 
arises  from  the  air  in  the  cavity  responding  to,  and  vibrating 
in  unison  with,  one  of  the  tones  comprised  in  the  sound  pro- 
duced by  striking"  the  coins.  The  note  being  thus  "  resonated  " 
or  reinforced,  and  the  vibrations  following  each  other  at 
regular  intervals,  a  musical  character  results.  The  fact  that 
the  bell  sound  is  not  always  heard  over  a  pneumothorax,  or, 
having  once  been  heard,  may  disappear,  is  probably  to  be 
explained  by  alterations  in  the  size  of  the  cavity  (fluid  tending 
to  replace  the  air),  or  by  variations  in  the  tension  of  the  con- 
tained air.  In  this  way  the  fundamental  tone  of  the  cavity 
becomes  altered,  and  reinforcement  of  the  coin  sound  is  ren- 
dered difficult. 

The  combination  of  auscultation  and  percussion  just 
described  has  been  employed  for  very  many  years,  but  more 
recently  a  modification  of  the  method  has  been  introduced 
with  the  hope  of  ascertaining  more  exactly  the  limits  of  the 
organs  within  the  chest,  and  especially  of  the  solid  organs, 
where  these  are  in  contact  with  other  substances  which  also 
yield  a  dull  note  to  percussion.  The  method  is  based  upon 
the  belief  that  the  vibrations  of  the  struck  coins,  or  of  a 
tuning-fork  placed  upon  the  chest  wall,  are  conducted  over 
the  chest  partly  through  the  parietes  and  partly  through  the 
underlying  viscera,  and  it  is  asserted  that,  so  long  as  the 
stethoscope  is  confined  to  the  organ  over  which  the  pleximeter 
coin  or  tuning-fork  is  placed,  the  sound  is  heard  with  com- 
paratively little  diminution  in  loudness;  but  so  soon  as  the 
limit  of  the  viscus  is  overstepped,  or  we  pass  from  one  lobe 
of  the  lung  to  another,  a  corresponding  hindrance  to  the  pas- 
sage of  vibrations  occurs,  and  the  sound  at  once  loses  much 
of  its  intensity.  We  have  tested  this  method,  but  have  not 
been  able  to  satisfy  ourselves  of  its  accuracy. 

Roentgen  Rays. 

After  examining  the  chest  in  the  manner  which  we  have 
described,  it  is  sometimes  advisable  to  supplement  our 
methods  by  the  employment  of  the  X-rays.  For  the  applica- 
tion of  Professor  Roentgen's  discovery  to  the  diagnosis  of 


64  DISEASES   OF  THE  LUNGS   AND  PLEURA 

diseases  of  the  chest  we  are  much  indebted  to  the  pioneer 
work  of  Dr.  Hugh  Walsham.  The  patient  may  be  examined 
by  means  of  the  screen  (radioscopy),  or  a  photograph  may 
be  taken  (radiography).  With  the  former,  in  addition  to  the 
shadows  which  alone  are  represented  in  a  photograph,  a 
lightening  and  deepening  of  the  shadows  during  inspiration 
and  expiration  respectively  can  sometimes  be  observed;  the 
movement  of  the  heart  and  diaphragm  can  be  also  studied,  as 
well  as  the  pulsation  of  any  abnormal  tumour  which  may 
happen  to  be  present.  But  in  a  doubtful  and  difficult  case  a 
photograph  (radiogram)  should  not  be  neglected,  since 
shadows  are  often  thus  demonstrated  with  greater  dis- 
tinctness. 

In  certain  chest  diseases  the  rays  prove  of  great  assistance. 
Thus,  in  a  case  in  which  the  diagnosis  lies  between  aneurism 
and  new  growth,  an  examination  with  the  screen  may  reveal 
the  sharply-defined  pulsating  shadow  so  suggestive  of  the 
former.  Similarly,  the  presence  of  a  foreign  body  in  the 
chest  may  be  shown,  and  its  situation  accurately  localised  by 
the  stereoscopic  method  invented  by  the  late  Sir  Mackenzie 
Davidson.  Again  in  hydatid  disease  of  the  lung  the  X-ray 
appearances  are  often  characteristic. 

In  pneumothorax  the  appearances  seen  are  instructive  and 
interesting,  but,  as  ordinary  cHnical  methods  are  generally 
sufficient  for  the  diagnosis,  the  rays  are  here  of  less  assistance. 
In  regard  to  the  early  diagnosis  of  phthisis,  symptoms  and 
physical  signs  have  in  our  experience  manifested  themselves 
as  a  rule  before  any  characteristic  X-ray  appearances.  <i 

Whilst  thus  fully  admitting  the  value  of  X-ray  examination 
as  an  additional  aid  in  the  diagnosis  of  certain  affections  of 
the  chest,  we  must  add  that  we  have  found  its  results  as  liable 
to  fallacy  as  other  methods  of  physical  examination,  and  it  is 
only  to  be  regarded  as  one  amongst  other  modes  of  diagnosis, 
including  the  history,  symptoms,  and  auscultatory  and  per- 
cussion signs,  in  the  complete  investigation  of  any  difficult 
case.  To  the  appearances  seen  in  the  various  forms  of  chest 
disease  we  shall  refer  in  greater  detail  in  the  succeeding 
chapters. 


PHYSICAL   EXAMINATION   OF  THE   CHEST  65 


REFERENCES. 

'  Inventum  novum  ex  fercussione  thoracis  humani  ut  signo  abstrusos 
interni  -pectoris  morbos  detegendi,  Leopold!  Auenbrugger,  Medicince 
Doctor  is.     Vindobonae,   1761. 

*  [a]  See  Auscultation  and  Percussion,  together  with  the  Other  Methods  of 

Physical  Examination   of  the   Chest,  by   Samuel  Gee,   M.D.,   p.    50, 
sixth  edition.     London,  1908. 
[b)  Loc.  cit.,  p.  114. 

*  De  la  Percussion  Midiate  et  des  Signes  Obtenus  a  VAide  de  ce  Nouveau 
Moyen  d' Exploration  dans  les  Maladies  des  Organes  Thoraciques  et  Abdo- 
minaux,  par  P.  A.  Piorry,  Docteur  en  Medecine,  p.  14.     Paris,  1824. 

■*  "  A  Uniform  Nomenclature  of  Auscultatory  Sounds  in  the  Diagnosis  of 
Diseases  of  the  Chest"  :  Provisional  Report  by  Professor  Austin  Flint  (New 
York),  Chairman  of  the  Committee,  Congres  Periodique  International  des 
Sciences  Medicates,  Copenhagen,  1884,  Compte-Rendu.  Copenhagen,  1886, 
tome  ii.,  p.  11. 

"  Hippocrates,  De  Morbis,  II.,  §  61. 

°  "  Recherches  sur  la  Cause  des  Bruits  Respiratoires  pergus  au  Moyen  de 
1' Auscultation,"  par  M.  Beau,  Archives  Ginerales  de  Medecine.  Paris, 
1834,  11^  serie,  tome  v.,  p.  557. 

'  "  The  Croonian  Lectures  on  the  Natural  History  and  Pathology  of 
Pneumonia,"  by  the  late  J.  W.  Washbourne,  C.M.G.,  M.D.,  F.R.C.P., 
The  Lancet,  1902,  vol.  ii.,  p.  1528. 

'  "  Contribution  k  I'Etude  du  M6canisme  des  Bruits  Respiratoires 
Normaux  et  Anormaux,'  par  MM.  A.  Bondet  et  A.  Chauveau,  Revue 
Mensuelle  de  Medecine  et  de  Chirurgie.     Paris,  1877,  tome  i.,  p.  161. 

^  {a)  "  Experiments  to  determine  the  Origin  of  the  Respiratory  Sounds," 
by  J.  F.  Bullar,  M.B.,  F.R.C.S.  Proceedings  of  the  Royal  Society, 
No.  234,  1884. 
{b)  "  On  the  Breath  Sounds  of  Health  and  Disease,"  by  J.  F.  Bullar, 
M.B.,  F.R.C.S.  .5"/.  Bartholomew'' s  Hospital  Reports,  vol.  xxi., 
1885,  p.  191. 

"  "  Some  Cases  illustrating  the  Pathology  of  Fatal  Haemoptysis  in 
Advanced  Phthisis,"  by  R.  Douglas  Powell,  M.D.,  Transactions  of  the 
Pathological  Society  of   London,    1871,   vol.   xxii.,   p.   48. 

"  Trait e  de  P Auscultation  Midiate  et  des  Maladies  des  Poumons  et  du 
CcEur,  par  R.  T.  H.  Laennec,  troisieme  Edition,  tome  i.,  pp.  120-122, 
Paris,  1831. 

'^  "  M^moire  sur  quelques  Faits  et  Apergus  Nouveaux,  relatifs  S,  1' Auscul- 
tation de  la  Poitrine,"  par  M.  Reynaud,  Journal  Hebdomadaire  de 
Midecine.     Paris,  1829,  No.  65,  p.  563. 

*'  "  The  Causation  of  ^gophony,"  by  Frederick  Taylor,  M.D.,  Trans- 
actions of  the  Royal  Medical  and  Chirurgical  Society,  1895,  vol.  Ixxviii., 
p.  127. 

'*  "Pneumothorax  :  Nouveau  Signe  Physique  Pathogncmonique  de  cette 
Affection."     See  Gazette  des  Hopitaux,  Paris,  1857,  p.  157. 

5 


CHAPTER  IV 

EXAMINATION  OF  THE  SPUTUM 

An  examination  of  the  contents  of  the  spittoon  should  never 
be  omitted  in  chest  ilhiess,  since  it  may  give  valuable  aid  in 
diagnosis. 
The  sputum  is  derived  chiefly  from  the  following  sources : 

1.  The  buccal  cavity,  yielding  saliva,  debris  of  food  and 
occasionally  blood. 

2.  The  naso-pharynx — in  conditions  of  catarrh. 

3.  The  trachea  and  bronchial  tract — in  tracheitis,  bronchitis, 
bronchiectasis  and  asthma. 

4.  The  lung  proper,  under  the  following  conditions :  — 

(a)  inflammation  or  oedema  of  the  infundibular  and 
alveolar  spaces,  as  in  pneumonia  and  oedema  of  the 
lung;  (b)  suppurative  or  other  destructive  changes  in 
the  lung — as  in  abscess,  phthisis,  hydatid,  or  growths ; 
(c)  the  rupture  of  vessels  or  of  an  abscess  or  other 
collection  into  or  through  the  lung,  as  in  aneurism, 
empyema  or  hepatic  abscess. 

Under  each  of  these  conditions  the  expectoration  is  to  some 
extent  characteristic,  and  it  is  therefore  obvious  how  varied 
must  be  the  appearances  of  the  sputum,  and  how  important 
the  information  to  be  gained  by  its  careful  and  minute  exam- 
ination— similar,  indeed,  to  -that  obtained  from  the  completely 
analogous  sedimentary  deposits  from  the  urine  in  kidney  and 
bladder  diseases. 

It  is  enough  here  to  have  alluded  to  the  main  sources 
whence  varied  forms  of  sputum  are  derived,  leaving  more 
detailed  descriptions  to  be  given  in  the  chapters  dealing  with 
the  diseases  referred  to.  We  propose,  however,  briefly  to 
describe  the  most  appropriate  methods  of  examining  sputum, 
and  more  especially  to  speak  of  its  microscopical  investi-. 
gation. 

66 


EXAMINATION   OF   THE    SPUTUM  6/ 

The  quantity,  reaction,  consistence,  colour  and  transparency 
of  the  sputum  should  be  carefully  noted. 

Quantity. — This  varies  considerably,  in  some  cases  being 
scanty,  in  others  very  large. 

The  largest  amount  is  brought  up  in  haemoptysis,  acute  pul- 
monary oedema,  or  when  an  empyema  bursts  through  the 
lungs.  In  bronchiectasis  also  the  expectoration  is  often  very 
copious,  at  times  seeming  almost  to  pour  out  of  the  mouth  of 
the  patient,  and  in  certain  forms  of  bronchitis  (broncho- 
blenorrhoea)  the  quantity  is  large.  In  phthisis,  too,  when 
cavities  exist,  a  great  amount  of  muco-purulent  material  is 
expectorated. 

Reaction. — The  reaction  of  sputum  is  always  alkaline. 
When  an  acid  reaction  is  obtained,  contamination  with 
vomited  matters  should  be  suspected. 

Consistence. — According  to  the  varying  proportions  of 
mucus  and  pus  present,  the  sputum  assumes  a  mucoid,  muco- 
purulent or  purulent  form.  Each  variety  may,  however,  from 
time  to  time  occur  in  the  course  of  any  one  disease. 

Mucoid  expectoration  is  glassy  and  transparent,  and  may  be 
quite  watery,  owing  to  a  large  amount  of  saliva  being  mixed 
with  it.  A  typical  example  of  mucoid  sputum  occurs  in  the 
early  stage  of  bronchitis.  Muco-purulent  expectoration  may 
be  of  any  consistency;  there  may  be  only  a  few  white  flakes 
floating  in  it,  or  it  may  consist  mostly  of  pus. 

Stratification  is  not  infrequently  noticed,  this  being  best 
observed  when  the  contents  of  the  spittoon  are  emptied  into 
a  conical  glass.  After  some  hours  three  layers  will  have 
formed,  the  uppermost  of  which  is  semi-opaque,  greenish- 
yellow  and  frothy,  containing  small  masses  and  balls,  hang- 
ing down  into  the  second  layer,  which  is  more  transparent  and 
watery.  The  undermost  layer,  composed  of  pus  cells  and 
decomposing  debris,  is  opaque  and  of  a  dirty  yellow  colour. 
Stratification  is  best  seen  in  cases  of  bronchiectasis. 

In  phthisis,  especially  where  there  are  moderate-sized  cavi- 
ties, the  sputum'  commonly  forms  flattened  lumps  of  rounded 
smooth  outline  floating  on  the  fluid  in  the  spittoon.  Each  of 
these  nitmmulated  masses  consists  of  a  collection  of  pus  which 
has  been  expelled  from  a  cavity,  and  has  become  moulded  and 
clothed  with  mucus  as  it  passes  through  the  bronchial  tract, 
thus  forming  a  separate  mass,  which  assumes  a  flattened  shape 


68  DISEASES    OF   THE   LUNGS   AND   PLEURA 

when  floating  on  water.     This  variety  is  sometimes  also  met 
with  in  bronchiectasis. 

Purulent  expectoration,  consisting  of  almost  pure  pus, 
occurs  only  when  an  abscess  in  the  lung  has  broken  through 
into  a  bronchus,  or  an  empyema  has  burst  into  the  lung. 

Serous  sputum  is  met  with  in  connection  with  acute  oedema 
of  the  lungs.  It  separates  into  an  upper  frothy  and  a  lower 
fluid  layer,  which  partially  or  completely  coagulates  on 
heating. 

Colour. — When  the  sputum  consists  only  of  mucus  and  a 
few  cells,  it  is  almost  clear.  If  pus  is  present,  it  becomes 
white  and  more  opaque;  and  if  the  quantity  of  pus  be  large, 
a  greenish  tinge  is  often  noticed. 

The  chief  differences  in  colour  are  caused  by  the  addition 
of  blood  or  blood-colouring  matter.  The  subject  of  haemo- 
ptysis will  be  more  fully  considered  in  a  later  chapter;  the 
more  remote  changes  which  blood  sometimes  undergoes  need 
only  be  mentioned  here. 

In  pneumonia  the  sputum  has  generally  a  rusty  tinge,  due 
chiefly  to  dissolved  haemoglobin,  as  red  corpuscles  are  present 
in  too  few  numbers  to  produce  the  colour.  In  rare  cases, 
quite  apart  from  any  jaundice,  the  pneumonic  sputum  may 
acquire  a  grass-green  colour.  This  generally  results,  as  Vcn 
Jaksch^  has  shown,  from  the  conversion  of  the  haemoglobin 
or  hasmatin  into  bilirubin,  and  the  oxidation  of  the  latter  into 
biliverdin.  Occasionally  grass-green  sputum  has  been  ob- 
served in  other  diseases,  such  as  asthma,  and  may  then  be 
traced,  as  pointed  out  by  Rosenbach,^  to  certain  pigment-form- 
ing micro-organisms  of  no  pathological  importance.  Towards 
the  end  of  the  pneumonic  attack  the  rusty  colour  gives  place 
to  a  saffron  or  citron-yellow  tinge,  the  same  colour  having 
been  observed  also  in  rare  cases  of  pulmonary  tuberculosis. 
Occasionally,  in  cases  of  pneumonia  which  run  an  unfavour- 
able course,  a  frothy,  watery,  dark  red  fluid,  known  as  prune- 
juice  expectoration,  is  coughed  up.  This  is  sometimes  also 
observed  in  sarcoma  or  cancer  of  the  lung. 

In  cases  of  tropical  abscess  of  the  liver  discharging  through 
the  lung,  the  expectoration  assumes  a  very  characteristic 
appearance,  and  has  been  likened  to  anchovy  sauce.  The 
colouring  matter  is  derived  in  this  case  from  the  presence  of 
red  corpuscles,  crystals  of  haematoidin,  and  disintegrated  liver 


EXAMINATION   OF   THE   SPUTUM  69 

cells,  which  give  the  reddish-brown,  brick-dust  colour.  The 
amoeba  of  dysentery  is  nearly  always  present. 

Occasionally  in  gunshot  wounds  of  the  chest  involving  the 
lung  and  liver,  bright  yellow  bile  may  be  met  with  in  the 
sputum.^ 

In  certain  manufacturing  districts  iron-dust  may  tinge  the 
expectoration  an  ochre  yellow  or  red  colour,  while  among 
coalminers  it  may  be  almost  black  from  the  inhalation  of  par- 
ticles of  carbon.  From  a  similar  cause  the  sputum  of  those 
who  dwell  in  large  towns  is  always  more  or  less  darkened. 

Bronchial  Casts. — Casts  of  the  bronchial  tubes,  composed  in 
most  cases  of  fibrin,  with  more  or  less  numerous  cellular 
elements  embedded,  are  sometimes  coughed  up.  These  are 
occasionally  expectorated  after  an  attack  of  haemoptysis,  and 
are  then  found  to  consist  of  fibrin  enclosing  in  its  meshes 
numerous  red  blood-corpuscles.  Their  red  colour  will  dis- 
tinguish these  casts  from  other  varieties.  Usually  such  casts 
are  small  in  size,  branching-  in  character  and  measure  perhaps 
a  couple  of  inches  in  length.  Occasionally,  however,  they 
are  very  much  larger,  as  in  the  beautiful  example,  apparently 
of  this  nature,  figured  in  the  "  Observationes  Medicae"  of 
Nicholas  Tulp.*  We  have  never  seen  a  cast  of  such  unusual 
size  expectorated  during  life,  although  we  have  removed  after 
death  following  haemoptysis  blood-casts  from  the  air-passage 
of  which  Fig.  10  illustrates  an  unusually  complete  example. 

Casts  consisting  of  complete  mouldings  of  the  trachea  and 
large  bronchi  are  still  sometimes  seen  in  cases  of  diphtheria, 
and  were  of  common  occurrence  before  the  introduction  of 
antitoxin.  More  often  they  are  smaller  and  have  their  origin 
in  the  second  and  third  divisions.  In  pneumonia,  casts  of  the 
finest  bronchi  are  not  infrequently  seen,  if  searcli  be  made  for 
them,  but  they  always  remain  small  in  size,  since  the  inflam- 
matory process  does  not  spread  beyond  the  finer  tubes.  It 
is,  however,  in  that  rare  disease  "  plastic "  or  "  membranous 
bronchitis,"  which  we  shall  consider  in  detail  in  a  later  chap- 
ter, that  the  most  perfect  bronchial  casts  are  to  be  observed. 

Microscopic  Examination. 

In  order  to  make  a  satisfactory  examination  of  the  sputum 
with  the  microscope,  the  selection  of  the  sample  is  important, 
all  food  materials  being-  so  far  as  possible  excluded.    For  this 


;'0  DISEASES   OF  THE  LUNGS   AND   PLEtTR^ 

purpose  the  morning  expectoration,  collected  before  any  food 
has  been  taken,  is  most  suitable  for  examination. 

The  sputum  should  be  poured  on  to  a  plate,  the  black  vul- 
canite dishes  used  by  photographers  being  well  adapted  for 
the  purpose.  Small  particles  should  be  picked  out  from  the 
general  mass  by  means  of  forceps  and  scissors,  placed  on  a 
glass  slide,  and  gently  flatt^uied  out  with  a  thin  cover-glass. 


Fig.  io. — Showing  a  Large  Blood-Cast  found  after  Death  in  the 
Air-Passages  of  a  Patient  who  had  died  from  H.^moptysis 
(reduced  to  §  Natural  Size). 

(From  the  Brompton  Hospital  Museum.) 

The  most  opaque  portions  should  generally  be  selected,  in 
which  may  be  observed  :  — 

Red  Blood  Cells  (Fig.  ii,  g),  the  individual  corpuscles  of 
which  usually  preserve  their  colour  and  discoidal  form,  though 
in  pneumonia  they  are  often  seen  as  pale  colourless  rings.  If 
the  blood  has  been  retained  for  some  time  in  the  lung,  the 
corpuscles  may  disappear,  and  be  represented  by  crystals  or 
irregular  particles  of  hsematoidin  (Fig  ii,  e). 

Leucocytes  and  Pus  Cells  (Fig.  ii,  /,  /')• — These  are  present 
to  some  extent  in  all  sputa,  and  if  the  expectoration  be  very 


EXAMINATION   OF   THE   SPUTUM 


71 


purulent  it  may  be  almost  composed  of  them.  The  variety 
chiefly  found  is  the  common  pus  cell  or  polymorphonuclear 
leucocyte.  The  cells  frequently  enclose  granules  of  fat  and 
particles  of  pigment;  on  addition  of  acetic  acid  the  tripartite 
nucleus  becomes  well  defined.  In  many  cases  of  asthma,  and 
in  some  of  bronchitis,  considerable  numbers  of  coarsely 
granular  eosinophile  cells  may  be  observed. 

Epithelium. — The  epithelial  cells  found  in  sputum  are  of 
three  kinds,  squamous,  ciliated  or  columnar,  and  alveolar. 

I.  Squamous  Cells  (Fig.  ti,  h)  are  derived  from  the  mouth, 
pharynx,  and  upper  part   of  the   larynx.     They  are  always 


Fig.    II. — Showing 


Crystals    found    in 


a,  a 


Epithelium,    Leucocytes,    and 
Sputum  (after  Von  Jaksch). 

a'>,  alveolar  epithelium;  b,  myelin  forms;  c,  ciliated  epithelium; 
d,  crystals  of  calcium  carbonate ;  e,  haematoidin  crystals  and  masses ; 
/,  /',  white  blood-corpuscles ;  g,  red  blood-corpuscles ;  k,  squamous 
epithelium.     (Eyepiece  III.,  Objective  8a,  Reichert.) 

present,  and  have  no  pathological  value.  When  the  sample  is 
very  liquid,  clear,  and  contains  only  these  cells  and  no  other 
form  of  epithelium,  it  may  be  concluded  that  the  specimen 
consists  of  saliva  only. 

2.  Ciliated  or  Columnar  Cells  (Fig.  11,  c)  are  derived  from 
the  greater  part  of  the  respiratory  passages,  including  the 
posterior  nares.  When  seen  in  large  numbers,  they  indicate 
a  catarrh  of  the  passages.  Cilia  are  only  found  attached  to 
them  when  the  inflammatory  process  is  very  acute. 

3.  Alveolar  Cells  (Fig.  11,  a,  a',  a")  from  the  air-vesicles  of 
the  lung  are  but  rarely  seen  in  a  perfect  condition.  They  are 
elliptical  in  shape,  each  containing  one  nucleus,  which  usually 
requires  acetic  acid  to  render  it  visible.  The  protoplasm  of 
the  cells  is  finely  granular,  and  often  contains  pigment  par- 
ticles.    Not  uncommonly  they  are  observed  to  be  undergoing 


72 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


fatty  degeneration,  and  occasionally  are  so  altered  as  to  be 
hardly  recognisable,  their  protoplasm  being  replaced  by  large, 
highly  refracting  particles,  named  by  Virchow  "  myelin  drop- 
lets "  (Fig  II.  b),  which  may  also  be  floating  free  in  the  sputum. 
Alveolar  cells  are  found  in  connection  with  various  diseases, 
and  neither  they  nor  the  myehn  droplets  have  any  diagnostic 
value. 

Elastic  Fibres,  when  present,  can  nearly  always  be  found  in 
opaque  portions  picked  out  from  the  sputum  as  above  directed. 

Another  method  generally  adopted  is  that  introduced  by  the 
late  Dr.  Samuel  Fenwick."  The  whole  of  the  sputum  for 
twenty-four  hours  is  collected  and  boiled  for  a  few  minutes  in 


>h- 


Fig.   12. — Elastic  Fibres  obtained  from  Sputum  after  a  Dose  of 
Tuberculin  had  been  administered. 

a  beaker,  with  an  equal  quantity  of  a  solution  of  caustic  soda, 
20  grains  to  the  ounce,  and  occasionally  stirred  with  a  glass 
rod,  until  it  becomes  diflluent.  As  soon  as  it  is  quite  liquid,  the 
mixture  is  thrown  into  a  conical  glass  containing  several  times 
its  bulk  of  water.  In  a  short  time  a  deposit  will  have  settled, 
and  portions  of  it  may  be  removed  with  a  pipette  and  placed 
under  a  microscope,  when  the  elastic  fibres  will  readily  be 
recognised.  The  liquid  may,  if  necessary,  be  centrifugalised. 
Care  must  be  taken  not  to  boil  too  long,  or  the  fibres  them- 
selves will  become  swollen  and  ultimately  dissolved. 

The  characteristics  of  these  fibres  (Fig.  12)  are  their  sharp- 
ness of  outline,  indestructibility,  dichotomous  branching,  and 
general  contour  marked  by  wide  curves  and  loops.     By  these 


EXAMINATION   OF  THE   SPUTUM 


73 


appearances  they  may  generally  be  distinguished,  but  some- 
times threads  of  cotton  or  the  mycelium  of  fungi  may  resemble 
them  somewhat  closely.  Under  these  circumstances  resort 
must  be  had  to  differential  staining,  elastic  fibres  taking  a 
brownish-violet  colour  with  acid  solution  of  orcein,  and  resist- 
ing decolourisation  on  subsequent  treatment  with  acid  alcohol, 
whilst  other  matters  are  but  faintly  stained. 

The  late  Sir  Andrew  Clark  was  the  first  to  insist  upon  the 
important  conclusions  that  may  be  derived  from  a  minute 
examination  of  the  elastic  fibres.  If  they  form  complete 
sheddings  of  the  alveoli,  the  morbid  process  is  a  very  acute  one, 
and  destruction  of  the  lung  is  proceeding  rapidly.  In  more 
chronic  conditions  only  small  "tailed"  pieces  will  be  found, 
which  have  lost  their  elasticity.  Fibres  may  sometimes  be 
found  which  have  been  re- 
tained in  the  lungs  for  a  long 
period  (one  to  two  years),  and 
have  become  encrusted  with 
lime  salts  (Fig.  13).  Such  in- 
crustations disappear  if  a  little 
dilute  acid  be  run  under  the 
-cover-glass. 

Although  met  with  chiefly 
and  in  largest  numbers  in 
the  sputum  of  phthisis,  elastic 
elements  are  also  found  in  the 
expectoration  from  cases  of 
pulmonary  abscess,  and  occa- 
sionally in  that  of  patients  suffering  from  bronchiectasis  or 
pneumonia.  In  cases  of  gangrene  of  the  lung  they  are  not 
met  with  as  often  as  might  be  expected,  being  destroyed  by 
the  ferments  formed  in  the  process.  Their  presence  in  the 
sputum  definitely  indicates  disintegration  of  lung  tissue. 

Occasionally  elastic  fibres,  unlike  those  which  we  have  been 
describing,  are  seen  in  straight  bundles.  If  the  individual 
fibres  composing  these  are  fine,  they  probably  come  from  the 
bronchi  or  larynx;  but  if  coarse,  food-matter  is  probably  their 
source,  and  this  will  be  corroborated  by  the  presence  of  small 
portions  of  muscular  tissue  adherent  to  them. 

Larger  fragments  of  lung  tissue,  in  the  form  of  dark  grey 
masses,  with  tags  and  shreds,  are  occasionally  met  with  under 


Fig.  13. — Elastic  Tissue  ENCRUSTED 
WITH  Lime  Salts. 


74 


DISEASES   OF  THE  LUNGS   AND  PLEURA 


similar  circumstances  to  the  above;  and  in  cases  of  deep 
ulceration  of  the  larynx  portions  of  cartilage  may  be  loosened 
and  expectorated. 

Curschmann's  Spirals.  —  These  bodies,  first  carefully 
described  and  figured  by  Curschmann,"  have,  as  their  name 
indicates,  a  peculiar  spiral  form.  They  may  be  recognised  by 
the  naked  eye  in  the  sputum  as  little  whitish  twisted  bodies 
about  an  inch  long  and  -^  inch  broad,  and  occasionally  very 
much  longer  (Fig.  14).  Under  the  microscope  they  are  found 
to  consist  of  a  central  highly  refracting-  wavy  thread,  around 
which  is  coiled  a  network  of  fine  fibres  having  a  spiral  arrange- 
ment, the  whole  being  surrounded  by  mucus  in  which  are  em- 
bedded numerous 
leucocytes  (Plate 
II.).  In  other  cases 
the  central  thread  is 
not  visible,  and  the 
spiral  appears  to  be 
composed  of  the  en- 
veloping coil  only; 
in  others,  again,  the 
central  thread  alone 
may  be  seen.  Chem- 
ically, the  central 
thread  would  seem 
to  be  composed  of 
fibrin,  the  spiral 
meshwork  encir- 
chng  it  being 
closely  allied  to 
mucin.  The  spirals 
were  first  observed  in  sputum  coughed  up  during  attacks  of 
spasmodic  asthma,  and  were  considered  to  be  diagnostic  of 
that  condition;  but  they  have  since  been  discovered  in  the 
expectoration  of  simple  bronchitis,  phthisis,  pneumonia  and 
oedema  of  the  lungs,  and  probably  indicate  nothing  more  than 
a  catarrh  of  the  finest  bronchial  tubes. 

Tonsillar  Casts. — In  cases  of  follicular  tonsillitis  casts  of  the 
tonsillar  crypts  are  not  infrequently  found  in  the  sputum. 
When  teased  out  they  are  seen  to  consist  of  fine  fibre-like 
bodies    of    varying    length;    more    usually    they    occur    in 


Fig.      14. — Showing     Naked-Eye     Appearance 
IN  THE  Sputum  of  Curschmann's  Spirals. 


fragments. 


PLATE  II 


CURSCHMANN'S  SPIRALS 

The  lower  drawing,  which  may  be  compared  with  Fig.  14, 
illustrates  a  spiral  under  a  low  degree  of  magnification.  The 
coiled  appearance  of  the  spiral  is  well  represented.  (After 
Curschmann.) 

In  the  upper  drawing  a  spiral  is  seen  under  a  higher  power. 
In  the  centre  is  a  highlj'  refractive  thread,  around  which  a  deli- 
cate festoon  is  coiled,  the  whole  being  surrounded  by  mucus,  in 
which  man}'  cells  are  enibedded.  (From  a  drawing  by  Dr.  W.  C. 
Fowler,     x  96.) 


PLATE  II 


■  *^- 


IS^ 


Curschmann's  Spirals. 


To  face  p.  74. 


EXAMINATION    OF    THE    SPUTUM 


75 


Crystals. — Crystals  of  various  forms  are  occasionally  met 
with  in  sputum,  the  best  known  being  the  "  Charcot-Leyden 
crystals"  (Fig.  15).  These  occur  as  colourless  pointed 
octahedra,  and  are  identical  with  those  sometimes  seen  in  the 
blood  in  leuksemia.  Their  chemical  nature  is  uncertain. 
Clinically  their  significance  is  small,  for  though  found,  often  in 
considerable  numbers,  in  the  sputum  after  an  asthmatic 
paroxysm,  they,  Hke  the  spirals,  may  also  occur  in  connection 
with  phthisis,  bronchial  catarrh  and  plastic  bronchitis,  as  well 
as  other  diseases.  They  would  seem  to  arise  from  the  dis- 
integration of  the  cellular  elements  in  the  sputum. 

Cholesterin  crystals  are  principally  associated  with  collec- 


FiG.  15. — Charcot-Leyden  Crystals,  from  a  Case  of  Asthma. 
(From  a  drawing  by  Dr.  W.  C.  Fowler  :    X  400.) 

tions  of  pus  in  pulmonary  abscess,  empyema  and  foetid 
bronchiectasis,  but  are  not  confined  to  these  conditions. 

Crystals  of  fatty  acid  appear  as  long  slender  needles,  often 
formed  into  rosettes.  They  are  very  common  in  the  sputa  of 
bronchiectasis  and  gangrene  of  the  lungs,  but  in  small 
numbers  occur  in  any  muco-purulent  expectoration,  especially 
if  it  has  been  kept  in  a  warm  place. 

Crystals  of  hasmatoidin  are  brownish-yellow  or  red  in  colour, 
and  take  the  form  of  rhombic  prisms  (Fig.  11,  e).  They 
indicate  that  blood  has  been  retained  for  some  time  in  the  air- 
passages,  and  are  numerous  after  an  haemoptysis. 

Crystals  of  tyrosin,  oxalate  of  lime  and  triple  phosphates, 
occasionally  occur,  but  their  presence  is  of  no  significance. 


76  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

Micro-organisms. — In  addition  to  the  bodies  which  we  have 
so  far  described  in  the  sputum,  numerous  micro-organisms  are 
to  be  found. 

Some  of  these,  such  as  the  tubercle  bacillus,  the  streptococci, 
the  pneumococcus,  varieties  of  the  streptothrix  group,  and 
many  others,  are  pathogenic  in  nature,  and  play  a  fundamental 
role  in  the  aetiology  of  pulmonary  disease.  It  is  not  our 
purpose  in  this  chapter  to  describe  these  organisms.  To 
many  we  shall  refer  again,  when  the  diseases  originated  by 
them  are  discussed,  and  for  a  more  detailed  description  we 
must  direct  the  reader  to  special  works  on  bacteriology. 

Others  are  saprophytic  in  nature,  or  if  pathogenic,  very 
feebly  so.  We  may,  for  instance,  find  in  the  expectoration  the 
long  bacillary  threads  of  a  variety  of  leptothrix,  or  little 
packets  of  cocci  forming  cubes  of  eight  produced  by  certain 
strains  of  sarcinae.  Neither  possess  any  pathological  signifi- 
cance, though  a  hasty  observer  might  mistake  the  former  for 
leashes  of  elastic  tissue.  Varieties  of  saprophytic  moulds  may 
also  be  encountered  in  the  sputum,  and  one  has  been  described 
by  the  late  Mr.  Coppen  Jones^  which  occurs  not  uncommonly 
in  phthisis,  in  which  disease  also  the  tetrads,  or  groups  of 
four  cocci,  formed  by  the  Micrococcus  tetragenus,  are  fre- 
quently to  be  found.  Occasionally  the  thrush  fungus,  Oidium 
albicans,  embedded  as  a  rule  in  masses  of  epithelial  debris, 
is  present  in  the  expectoration. 

Adventitious  Matters. — The  sputum  sometimes  contains 
other  substances  than  those  already  referred  to.  In  a  few 
cases  these  bodies  are  of  much  diagnostic  importance;  for 
instance,  the  fragments  of  new  growth  sometimes  coughed 
up  in  the  course  of  malignant  disease  of  the  lung,  the  booklets 
of  hydatids,  the  ova  of  the  lung  fluke,  Paragonimus  Ringeri, 
in  endemic  haemoptysis,  and  the  hairs  occasionally  yielded  by 
mediastinal  dermoid  cysts.  Of  pathological  interest  also  are 
the  white  cretaceous  masses  coughed  up  by  certain  phthisical 
patients. 

It  must  not  be  forgotten  that  the  sputum  may  contain 
matters  which  are  purely  extraneous,  such  as  grape-skins, 
nutshells,  orange-pips,  linen,  cotton,  silk  or  woollen  fibres, 
particles  of  animal  and  vegetable  tissues,  starch  granules,  fat, 
and  so  forth.  These  are  obviously  accidental,  and  have  only 
found  their  way  into  the  spittoon  by  chance;  but,  unless  their 


EXAMINATION   OF   THE    SPUTUM  yj 

nature  be  recognised,  they  are  likely  to  be  mistaken  for 
some  of  the  pathological  constituents  of  the  expectoration, 
which  we  have  already  described. 


REFERENCES. 

^  Clinical  Diagnosis,  by  Rudolf  v.  Jaksch,  M.D.,  edited  by-  Archibald 
E.  Garrod,  M.D.,  p.  165.     London,  1905. 

^  Ueber  eine  neue  Art  von  Grasgriinem  Sputum,"  von  Dr.  Ottomar 
Rosenbach  (zu  Jena),  Berliner  Klinische  WochenscJirift,  1875,  p.  645. 

^  "A  Case  of  Cholo-Haemothorax,"  by  T.  R.  Elliott,  F.R.S.,  F.R.C.P., 
and  Herbert  G.  M.  Henry,  M.D.,  British  Medical  Journal,  1916,  vol.  i.,  p.  9. 

*  Nicolai  Tulfii  Amstelredamensis  Observationes  Medicae,  apud 
Danielem  Elzevirium,  Amstelredami,  p.   116,   1672 

^  "  On  the  Detection  of  Lung-Tissue  in  the  Expectoration  of  Persons 
affected  with  Phthisis,"  by  Samuel  Fenwick,  M.D.,  Transactions  of  the 
Royal  Medical  Chirurgical  Society,  London,  1866,  vol.  xlix.,  p.  209. 

*  "  Ueber  Bronchiolitis  Exsudativa  und  ihr  Verhaltniss  zum  Asthma 
nervosum,"  von.  H.  Curschmann  (in  Hamburg),  Deutsches  Archiv  fiir 
Klinische  Medicin,  1883,  Band  xxxii.,  p.  i. 

^  "  Ueber  einen  neuen,  bei  Tuberkulose  haufigen  Fadenpilz,"  von 
A.  Coppen  Jones,  F.L.S.,  in  Davos,  Centralblatt  fiir  Bakteriologie  und 
Paracitenkunde,  Jena,  1893,  Band  xii.,  p.  697. 


CHAPTER  V 

DEFORMITIES  AND  DISEASES  OF  THE  CHEST  WALLS 

Tpie  shape  of  the  chest  is  nicely  conformed,  as  a  rule,  to  the 
condition  of  the  lungs.  Thus  we  have  the  small,  long  thorax 
with  oblique  approximated  ribs  associated  with  small  lungs; 
the  large,  expanded,  barrel-shaped  chest  with  emphysematous 
lungs;  and  the  local  flattening  or  enlargement  met  with  in 
certain  pulmonary  or  pleuritic  diseases.  To  these  we  shall 
have  occasion  to  refer  again.  We  may  now  consider  certain 
alterations  in  the  shape  of  the  chest  which  deserve  special 
attention. 

1.  The  Pigeon  Breast. — On  the  surface  of  the  chest  in  the 
inframammary  region  of  each  side  there  exists  an  area,  having 
the  fifth  space  in  the  nipple  line  for  its  centre,  which  is  un- 
supported by  muscles.  This  space  occupies  the  interval 
between  the  insertions  of  the  pectoralis,  the  serratus,  and  th,e 
rectus  m.uscles,  and  in  any  obstruction  to  the  entry  of  air  into 
the  lungs,  the  atmospheric  pressure  is  here  least  supported  by 
muscular  action.  Hence,  in  young  children  in  whom  the  ribs 
and  cartilages  readily  yield  in  any  condition  of  general 
dyspnoea,  this  part  of  the  chest  on  each  side  becomes  depressed 
and  the  sternum  tilted  outwards.  Repeated  bronchial  attacks 
thus  give  rise  to  the  prominent  sternum  and  depressed  inferior 
and  lateral  thorax  which  persist  and  constitute  the  pigeon 
breast,  a  deformity  which  is  intensified  by  the  drawing  in  of  the 
lower  chest  by  the  action  of  the  diaphragm  along  its  zone  of 
attachment. 

2.  In  the  Rickety  Thorax  a  more  or  less  deep  groove  corre- 
sponds on  each  side  with  the  junction  of  the  ribs  and  their 
cartilages,  there  being  here  a  knuckling  in,  so  to  speak,  of  the 
ribs,  causing  the  sternum  to  come  forward  with  undue  promi- 
nence.    This  is  due  to  atmospheric  pressure  depressing  the 

78 


DEFORMITIES  AND  DISEASES  OF  THE  CHEST  WALLS        79 

softened  and  unresisting  portions  of  the  ribs  and  their  adjacent 
cartilages. 

3.  The  Alar  Chest. — It  has  been  known  since  the  time  of 
Aretaeus,*  and  possibly  was  recognised  even  before,  that  in 
patients  suffering  from  phthisis,  or  merely  predisposed  to  this 
disease,  the  chest  is  often  small  and  narrow.  As  a  consequence 
there  is  insufficient  breadth  of  support  for  the  scapulae,  the 
superior  angles  of  which  are  thrown  forward  and  inward  by 
the  weight  of  the  arms,  and  the  inferior  angle  tilted  outwards. 
The  effect  upon  a  thin  subject,  when  viewed  from  behind,  is 
thus  to  produce  a  winged  appearance,  to  describe  which  the 
terms  "alar  "  or  "  pterygoid  "  have  been  employed. 

Another  deviation  from  the  normal  in  the  shape  of  the  chest 
is  the  cup-like  hollow,  which  is  from  time  to  time  seen  over 
the  lower  portion  of  the  sternum  and  the  adjacent  cartilages. 
This  is  sometimes  produced  by  occupations,  such  as  that  of  a 
shoemaker,  in  which  persistent  pressure  is  made  upon  the 
lower  sternal  region.  The  deformity  also  occurs  in  a  marked 
degree  when  no  history  of  pressure  can  be  obtained,  and  may 
then  be  attributed  to  obstructed  respiration  during  childhood.- 

Lastly,  we  may  mention  a  deformity  due  to  a  deficiency  of 
the  clavicular  portion  of  the  pectoralis  major  muscle  on  one 
side,  of  which  we  have  seen  some  examples.  A  remarkable 
flattening,  or  rather  hollowing,  below  the  clavicle  is  thus  occa- 
sioned, suggestive  of  grave  internal  lesion.  The  true  cause  of 
the  depression  is,  however,  at  once  rendered  obvious  by 
making  the  patient  grasp  the  back  of  a  chair  with  both  hands 
and  attempt  to  lift  it,  when  the  existing  muscular  fibres  start 
into  action,  and  the  defect  is  declared. 

Let  us  now  turn  to  the  diseases  of  the  chest  walls,  which 
are  of  importance  chiefly  from  the  frequency  with  which  they 
simulate  more  deeply-seated  lesions. 

Pleurodynia  {-n-Xevpa,  the  side,  dSuv?/,  pain). — This  may  be 
due  to  rheumatism;  m^yalgia,  or  intercostal  neuralgia.  The 
symptoms  are  very  similar  in  all  these  conditions,  but  more 
particularly  in  the  two  first  named,  and  there  can  be  no  doubt 

*  Aretffius'  {circa  a.d.  50)  thus  describes  the  chest  of  phthisis  :  "  .  .  .  the 
whole  shoulder-blades  apparent  like  the  wings  of  birds.  .  .  .  The  habits 
most  prone  to  the  disease  are  the  slender ;  those  in  which  the  scapulae 
protrude  like  folding-doors,  or  like  wings ;  in  those  which  have  prominent 
throats ;  and  those  which  are  pale  and  have  narrow  chests." 


8o  DISEASES   OF   THE   LUNGS   AND   PLEURA 

that  aponeurotic  rheumatism  and  myalgia  are  conditions  fre- 
quently associated  and  difficult  to  distinguish.  Pleurodynia 
commonly  begins  quite  suddenly  with  severe  pain  of  a  tingling 
or  burning  character  much  aggravated  by  respiratory  move- 
ments, especially  those  of  deep  inspiration  or  tussive  expira- 
tion. The  pain  may  be  situated  at  any  part  of  the  chest,  but  a 
common  seat  is  over  the  insertion  of  the  pectoral  muscle  in 
front,  or  at  the  margin  or  sides  of  the  chest  where  the  recti  and 
serrati  muscles  are  attached.  When  the  pain  is  lateral,  it  is 
limited  to  one  side.  '  The  breathing  of  the  patient  is  hampered, 
and  may  even  be  greatly  distressed  by  the  severity  of  the  pain. 

Aponeurotic  Rheumatism  is  not  common  before  thirty, 
although  it  may  occur  in  young  people  of  distinctly  rheumatic 
diathesis.  It  is  frequently  consequent  upon  direct  exposure  to 
cold,  especially  in  persons  coming  from  hot  rooms  and  when 
overheated  by  exertion.  Middle-aged  and  elderly  people,  who 
are  the  subjects  of  gout  and  allied  rheumatic  affections,  such 
as  lumbago  and  sciatica,  are  specially  liable  to  this  affection. 

Myalgia,  except  in  so  far  as  muscular  tenderness  is  inevitably 
more  or  less  associated  with  the  preceding  condition,  is  gen- 
erally traceable  to  strain.  It  sometimes  occurs  in  whooping- 
cough,  and  very  commonly  in  the  course  of  phthisis. 
Unquestionably  the  disease  has  in  most  instances  a  definite 
pathology  in  the  rupture  of  some  minute  muscular  fibres. 

Intercostal  Neuralgia  is  a  more  definite  ailment  than  either 
of  the  above,  and  occurs  more  especially  in  females,  at  two 
periods  of  life,  and  in  two  formis.  (i)  It  is  very  common  in 
young  women  in  the  form  of  inframammary  neuralgia,  in 
which  the  pain  is  referred  to  the  surface  of  the  chest  below 
the  left  breast.  This  affection  is  most  generally  associated 
with  anaemia  attended  with  leucorrhoea,  amenorrhoea  or  other 
menstrual  disturbance.  (2)  It  also  occurs  in  persons  of  middle 
or  advanced  middle  life  and,  again,  is  more  common  in  females. 
In  this  form  the  pain  is  of  a  very  severe  stinging  or  burning 
character  along  the  course  of  the  peripheral  distribution  of 
one  or  more  of  the  intercostal  nerves.  It  may  last  for  days  or 
even  weeks,  and  then  be  followed  by  the  appearance  of  the 
characteristic  eruption  of  herpes  zoster,  after  which  the 
pain  is  soon  mitigated,  or  subsides  altogether.  This  disease 
appears  to  be  commonly  associated  with  the  rheumatic 
or  gouty  diathesis.     Although  most  common  in  females  of 


DEFORMITIES  And  diseases  of  the  chest  walls       8  I 

middle  age,  it  is  by  no  means  limited  to  them,  and  may  some- 
times be  observed  in  quite  young  people.  The  pain  attendant 
upon  herpes  zoster  in  the  young,  however,  is  not  often  severe, 
and  rarely  precedes  the  appearance  of  the  eruption  by  any 
considerable  time. 

Diagnosis. — The  distinctive  signs  of  pleurodynia,  when  care- 
fully considered,  are  quite  sufficient  for  diagnosis : 

1.  The  disease  per  se  does  not  raise  the  temperature,  in 
which  fact  we  have  one  very  important  element  in  the  diagnosis 
from  pleurisy. 

2.  There  is  usually  decided  tenderness  on  pressure  over  the 
seat  of  pain.  In  intercostal  neuralgia  this  tenderness  is  very 
superficial  and  is  best  elicited  by  gently  pinching  up  the  skin. 
The  tenderness  may  be  observed,  too,  not  only  over  the  point 
most  complained  of,  but  also  in  the  lateral  spinal  region  corre- 
sponding with  the  distribution  of  the  posterior  cutaneous 
branches  of  the  affected  nerves.  In  cases  in  which  the  pain 
is  chiefly  situated  below  the  left  breast,  the  patient  usually 
presents  other  signs  of'  ansemia.  In  myalgia  the  pain  is 
markedly  elicited  by  bringing  the  muscles  affected  into  action, 
asking  the  patient,  for  example,  to  grasp  the  back  of  a  chair, 
thus  bringing  the  pectoral  muscles  into  action,  or  to  raise 
himself  in  bed  or  turn  on  one  side  so  as  to  involve  other 
muscles.  In  aponeurotic  rheumatism  and  in  myalgia  there  is 
also  tenderness  on  firm  pressure  over  the  muscles  in  the  inter- 
costal spaces. 

3.  The  respiratory  movements  are  restrained  by  the  pain, 
and  respiration  on  the  affected  side  is  correspondingly  weak; 
but  it  is  of  vesicular  character,  and  unattended  with  any 
friction  sounds.  One  may  sometimes  hear,  however,  mus- 
cular vibratile  sounds,  due  to  the  voluntary  restraint  exercised 
upon  this  side  by  the  patient.  The  percussion  resonance  is 
unaltered. 

Pleurisy  and  pericarditis  are  the  two  conditions  most  simu- 
lated by  pleurodynia.  In  phthisical  subjects,  where  there  is 
perhaps  already  existing  pyrexia,  it  is  often  difficult  to  be  sure 
that  there  is  not  some  dry  pleurisy,  but  here  the  diagnosis  is 
not  very  important.  Aponeurotic  rheumatism  of  the  front  of 
the  chest  is  distinguished  from  pericarditis  by  the  absence  of 
the  physical  signs  proper  to  that  disease. 

Treatment. — Intercostal  neuralgia  in  young  anaemic  subjects 

6 


82  DISEASES   OF  THE  LUNGS  AND   PLEURA 

requires  general  treatment  by  iron,  quinine,  arsenic,  and  fresh 
air,  with  generous  diet;  also  local  treatment  by  soothing 
applications,  such  as  belladonna  plasters,  or  chloroform  liniment 
(3  parts)  with  belladonna  liniment  (i  part),  sprinkled  on  lint  or 
flannel  backed  by  oiled  silk.  Menthol,  dissolved  in  liniment  of 
chloroform  (3i.  in  §i.),  may  be  applied  in  a  similar  manner,  or 
the  Linimentum  Aconiti  Compositum  containing  equal  parts 
of  the  liniments  of  aconite,  belladonna,  and  chloroform. 
Aconite  and  belladonna  may  also  be  efficaciously  applied  in 
the  form  of  the  Chloroformum  aconiti,  or  Chloroformum 
belladonnee  of  Messrs.  Squire,  the  remedy  being  painted  with 
a  camel's-hair  brush  over  the  painful  part.  Another  prepara- 
tion which  sometimes  gives  relief  when  painted  on  the 
skin  is  "  Kasemol,"  which  is  believed  to  contain  menthol, 
methyl  salicylate,  the  oils  of  mustard  and  sassafras  and  the 
essential  oil  of  camphor.  In  the  herpes  zoster  form  of  inter- 
costal neuralgia,  before  the  eruption  appears,  the  same  reme- 
dies may  be  used;  afterwards  the  local  application  must  be 
used  with  caution.  In  this  latter  variety  of  neuralgia,  the  pain 
is  often  very  severe  and  intractable,  and  subcutaneous  injec- 
tions of  morphia  and  atropine  may  be  required.  Local  deple- 
tion by  leeches  will  always  give  temporary  relief,  but  in  the 
anaemic  form  of  neuralgia  this  method  of  treatment  is  not  to  be 
advised.  The  myalgic  forms  of  pleurodynia  are  best  treated 
by  keeping  the  affected  side  of  the  chest  at  rest  by  strapping, 
as  for  dry  pleurisy.  Aponeurotic  rheumatism  may  often  at 
once  be  cured  by  the  application  of  a  well-made  mustard 
poultice  kept  on  for  twenty  minutes.  In  the  case  of  any  rheu- 
matic diathesis,  general  remedies,  especially  iodide  of  potas- 
sium with  quinine  and  salicylates  or  aspirin,  will  be  required. 

Periostitis  and  Perichondritis  of  Sternum  and  Ribs. — This 
is  a  disease  which  comes  under  the  notice  of  the  physician  not 
very  infrequently,  and  which  sometimes  gives  rise  to  perplexity 
in  diagnosis.  It  is  generally  the  result  of  syphilis,  typhoid 
fever  or  tubercle,  and  is  occasionally  met  with  in  the  course 
of  pulmonary  phthisis. 

When  due  to  tubercle,  the  tuberculous  process  may  start  as 
a  small  area  of  central  caries  in  the  middle  of  the  rib  (Fig.  16), 
and  then  spread  through  the  bone  to  the  periosteum;  or  it 
may  commence  near  the  surface,  and  attack  the  superficial 
layer  of  bone  and  the  periosteum  simultaneously.     In  which- 


DEFORMITIES  AND  DISEASES  OF  THE  CHEST  WALLS 


83 


ever  way  it  starts  it  eventually  forms  an  abscess,  which  as  a 
rule  points  forwards;  but  if  the  disease  has  commenced  on  the 
inner  aspect  of  the  rib  or  sternum,  a  large  collection  of  pus 
may  form  here,  separating  the  pleura  from  the  ribs,  compres- 
sing the  lung,  and  simulating  most  closely  an  empyema. 
These  cases  are,  happily,  rare,  and  as  a  rule  the  formation  of  a 
small  swelling  over  the  sternum  or  an  adjacent  rib,  accom- 
panied by  but  little  pain,  is  the  first  sign  which  attracts  the 
patient's  attention  and  causes  him  to  seek  advice.  If  treated 
at  once  surgically  by  evacuation  of  the  pus  and  removal  of  any 
dead  bone,  the  disease  is  generally  cured;  but  if  left  untreated, 


Fig.    16. — Tuberculous  Osteo-Myelitis  of  Rib. 

The  specimen  shows  the  outer  surface  of  the  fourth  right  rib  and  cartilage, 
and  also  the  appearances  seen  when  a  section  was  made  and  the  parts 
opened  outwards.  A  central  area  of  disease  is  visible,  the  size  of  a 
pea,  which  communicated  during  life  with  a  costal  abscess  by  the 
small  hole  seen  in  the  figure.  Removed  by  operation  from  a  man 
suffering  from  chronic  pulmonary  tuberculosis.  (From  the  Brompton 
Hospital  Museum.) 

the  pus  may  burrow  and  cause  extensive  lesions.     We  have 
seen  complete  necrosis  of  the  sternum  thus  produced. 

In  the  case  of  typhoid  fever,  the  inflammation,  whether  in 
connection  with  the  sternum  or  a  rib,  is  generally  produced  by 
the  direct  action  of  the  typhoid  bacillus,  though  sometimes  it 
is  the  result  of  secondary  infection  by  the  pyogenic  micro- 
organisms.^ The  symptoms  resemble  those  of  the  tuberculous 
cases,  although  they  may  terminate  in  spontaneous  resolution. 
In  a  case  of  this  kind  seen  by  one  of  us  some  time  ago,  the 
symptoms,  local  prominence  over  the  first  two  ribs,  obscured 
breath-sounds,  some  venous  engorgement,  and  great  tender- 


84  DISEASES   OF   THE   LUNGS   AND   PLEURA 

ness,  were  traceable  to  an  attack  of  typhoid  fever  four  or  five 
months  previously,  and  suggested  at  first  the  diagnosis  of  a 
local  abscess  or  empyema.  The  lady,  however,  ultimately, 
though  slowly,  recovered,  without  operation,  under  repeated 
and  prolonged  change  of  air  and  other  remedies. 

In  syphilis,  periosteal  nodes  over  the  sternum  (especially  its 
upper  portion)  and  over  the  ribs  are  not  uncommon;  more 
rarely  gummata  breaking  down  into  ulcerating  sores  may  be 
observed.  Tubercle  or  malignant  disease  may  be  suspected, 
but  it  should  be  a  rule  in  any  doubtful  case  to  administer  a 
course  of  antisyphilitic  treatment.  Occasionally  pulsation 
may  be  conveyed  to  a  softened  gumma,  and  suggest  the 
diagnosis  of  aneurism. 

Fascial  Creaking. — Before  concluding  this  chapter,  we  must 
mention  a  very  curious  physical  sign,  the  so-called  fascial 
creaking  which  may  be  heard,  especially  over  the  supraspinous 
and  scapular  regions.  This  phenomenon  is  attended  with  a 
certain  amount  of  pain.  We  have  met  with  cases  of  this  kind 
which  have  been  treated  with  great  perseverance  for  many 
weeks  by  blisters  and  iodine  counter-irritants,  under  the 
impression  that  the  patients  were  suffering  from  chronic 
pleurisy.  The  condition  is,  however,  so  far  as  we  have  been 
able  to  observe,  a  permanent  one,  and  is  only  important  in 
diagnosis.  If  the  attention  be  once  awakened  to  the  possi- 
bility of  the  sounds  being  extrathoracic,  the  diagnosis  can  be 
confirmed  by  making  the  patient  stop  breathing  and  by  Hsten- 
ing  whilst  the  shoulder  is  shifted  about,  when  the  creakine 
will  still  be  heard. 


REFERENCES. 

^  The  Extant  Works  of  AretcEus  the  Caffadocian,  edited  and  translated 
by  Francis  Adams,  LL.D.  "  On  the  Causes  and  Symptoms  of  Chronic 
Diseases,"  bk.  i.,  chap,  viii.,  p.  311,  London,  1856. 

*  Auscultation  and  Percussion,  by  Samuel  Gee,  M.D.,  p.  32,  fourth 
edition,  London,  1893. 

'  On  the  Typhoid  Bacillus  and  Typhoid  Fever,  by  P.  Horton-Smith 
(Hartley),  p.  64.     London,  1900. 


CHAPTER  VI 

DISEASES  OF  THE  PLEURA 

Pleurisy. 

The  pleura  on  each  side  of  the  chest  is  a  closed  serous  cavity 
or  sac  intimately  applied  to,  and  in  organic  union  by  its 
outer  surface  with  the  lung  and  the  costal  parietes.  The 
internal  surface  of  the  sac  is  Hned  with  endothehum,  the 
costal  and  parietal  portions  being  in  close  contact,  lubricated 
merely  by  some  moist  serous  secretion.  This  contact  or 
apposition  is  maintained  by  atmospheric  pressure  bearing 
upon  the  interior  of  the  lung  and  the  exterior' of  the  chest 
wall,  which  more  than  counterbalances  the  constant  tendency 
of  the  two  surfaces  of  the  sac  to  spring  apart  from  the 
opposite  elastic  tractions  of  the  lung  and  thoracic  wall. 

The  pleura  is  well  provided  with  bloodvessels,  which  are 
derived  from  the  bronchial,  internal  mammary  and  inter- 
costal arteries. 

The  lymphatics  consist  of  two  series,  the  one  forming  a 
network  beneath  the  surface  endothelium,  the  other  situated 
in  the  cellular  tissue  subjacent  to  the  pleura.  Both  series 
communicate  freely  with  each  other.  In  the  visceral  portion 
of  the  pleura  the  lymphatics  communicate,  as  we  have  indi- 
cated elsewhere  (see  p.  i8),  with  the  pulmonary  lymphatics, 
and  both  are  drained  by  the  superficial  collecting  trunks  into 
the  bronchial  glands  at  the  hilum  of  the  lung.  The  parietal 
pleura,  so  far  as  its  costal  portion  is  concerned,  is  drained  by 
the  deep  intercostal  lymphatics,  and  thus  by  the  internal 
mammary  vessels  and  glands;  the  lymphatics  of  the 
mediastinal  pleura  terminate  in  the  posterior  mediastinal 
glands.  The  communication  of  the  superficial  and  deep 
intercostal  lymphatics,  and  the  connection  of  the  former 
with  the  lymphatics  of  the  chest  wall,  explains,  as   Poirier 

85 


86  DISEASES   OF   THE   LUNGS   AND   PLEURA 

and  Cuneo'  point  out,  the  affection  of  the  axillary  glands 
which  is  sometimes  observed  in  deep-seated  thoracic  disease. 
The  important  connection  existing"  between  the  lymphatics  of 
the  pleural  and  peritoneal  surfaces  of  the  diaphragm,  and 
also  between  the  lymphatics  of  the  liver  and  those  of  the 
diaphragmatic  pleura,  has  already  been  referred  to  (see  p.  19). 

When  we  regard  the  position  and  connections  of  the  pleura, 
its  extensive  endothelial  surface,  the  conditions  of  negative 
pressure  in  which  that  surface  is  ever  maintained,  and  its 
richness  in  lymphatics,  we  cannot  wonder  that  it  should  fre- 
quently become  the  seat  of  disease,  nor  that  it  should  be  ont 
of.  the  chosen  sites  for  the  manifestation  of  lesions  resulting 
from  blood  infection.  Few  are  the  autopsies  after  adult,  age 
in  which  one  fails  to  find  some  imperfections  in  the  pleura; 
few  are  the  cases  of  septic  or  pygemic  poisoning  in  which  this 
membrane  is  not  actively 'involved. 

Pleurisy,  as  the  physicians  of  the  early  Roman  Empire 
knew  full  well,  is  an  inflammation  of  the  pleural  membrane; 
"  Under  the  ribs,  the  spine,  and  the  internal  part  of  the 
thorax,  as  far  as  the  clavicles" — so  writes  Aretseus^ — "there 
is  stretched  a  thin,  strong  membrane,  adhering  to  the 
bone.  .  .  .  When  inflammation  occurs  in  it  .  .  .  the  affec- 
tion is  named  pleurisy."  Clinically,  however,  cases  differ 
much  among  themselves,  and  various  forms  of  the  disease 
are  recognised.  A  classification  based  upon  bacteriology 
alone  would  not  give  an  adequate  presentment  of  the  disease 
in  its  varying  characteristics.  It  has  not  as  yet  been  shown  that 
in  all  cases  a  micro-organism  is  responsible  for  it,  although 
no  doubt  it  is  so  in  the  great  majority  of  instances.  Again, 
the  same  microbes,  for  example,  the  pneumococcus  or  the 
tubercle  bacillus,  will  produce  at  different  times  and  in  varying 
circumstances  quite  different  forms  of  pleurisy.  We  shall, 
therefore,  under  the  common  heading  "Inflammation  of  the 
Pleura,"  describe  the  aetiology  and  characters  of  the  following 
groups,  viz.:  (a)  Plastic  or  dry  pleurisy;  (b)  Pleurisy  with 
effusion,  whether  sero-fibrinous,  hjemorrhagic  or  purulent. 

I.  Fibrinous,  Plastic,  or  Dry  Pleurisy. — This  variety  of 
pleurisy  consists  in  an  inflammation  of  the  membrane,  lead- 
ing to  the  exudation  of  lymph,  usually  over  a  limited  area  of 
its  , surface.  Beyond  this  stage  the  inflammatory  process 
does  not  pass,  and  after  a  time  the  lymph  is  absorbed,  or 


DISEASES    OF   THE   PLEURA  87 

adhesions  form,  binding'  the  surfaces  to  each  other.  The 
disease  may  be  either  primary — occurring",  that  is  to  say, 
in  the  absence  of  any  evident  lesion  of  the  lung — or  secondary 
to  the  spread  of  inflammation  (whether  tuberculous  or  other- 
wise) from  the  lung  or  chest  wall,  or  to  some  general  blood 
infection.  True  primary  cases  are  rare,  many  of  those 
which  at  first  seem  to  be  of  this  nature  proving  eventually 
to  be  the  result  of  tuberculous  disease  of  the  lung  which  has 
not  as  yet  given  rise  to  symptoms. 

Pathology. — The  pathology  of  the  disease  may  be  briefly 
described  as  consisting  in  the  first  place  of  hypersemia  of  the 
pleura;  within  a  very  few  hours  the  normal  glistening  appear- 
ance of  the  surface  is  lost;  it  becomes  cloudy,  as  though 
breathed  upon,  and  gradually  covered  with  a  layer  of  exuded 
lymph.  Both  the  costal  and  visceral  layers  are  thus  affected, 
and  the  result  of  the  movement  of  the  two  surfaces  upon 
each  other  is  to  roughen  them,  causing  the  effused  lymph  to 
present  numerous  httle  elevations  and  pittings,  like  the  fretted 
surface  of  a  lake. 

At  this  point  the  disease  may  come  to  a  standstill,  and  the 
exuded  lymph  be  gradually  again  absorbed.  The  pleura  in 
this  case  once  more  becomes  smooth,  but  the  site  of  the  old 
lesion  is  generally  revealed  by  a  thickening  and  opacity  of 
the  membrane,  and  sometimes  by  a  sHght  radiated  pucker- 
ing, due  to  the  formation  of  a  thin  layer  of  fibrous  tissue. 
More  often  the  lymph  exuded  is  not  simply  absorbed,  but 
vascular  loops  extend  into  it  from  the  pleural  vessels  on 
either  side,  which  meet  and  inosculate,,  giving-  rise  to  the 
formation  of  permanent  adhesions.  As  a  rule,  these  are  not 
of  great  density,  but  where  there  is  much  shrinking  of  the 
lung,  as  in  many  cases  of  phthisis,  they  become,  as  we  have 
shown  elsewhere,''  stretched  and  filled  with  fluid,  and  present 
a  gelatinous  aspect  (Plate  XXII.,  Frontispiece).  Organisa- 
tion slowly  follows,  and  leads  to  the  formation  of  firm  and 
dense  adhesions,  which  measure  not  uncommonly  at  the  apex 
of  the  lung  J  inch  or  more  in  thickness. 

On  rare  occasions,  without  previous  disease  of  the  lung, 
tubercle  attacks  the  pleura,  and  gives  rise  to  a  somewhat 
similar  condition,  termed  by  the  late  Sir  William  Osier* 
"chronic  adhesive  tubercular  pleurisy."  In  this  disease  the 
pleura  over  the  whole  lung;  becomes,  by  the  gradual  develop-- 


88  DISEASES   OF   THE   LUNGS   AND   PLEUR/5: 

ment  of  tubercles,  greatly  thickened,  measuring',  perhaps,  i  to 
I  inch  across.  On  section,  the  tissue  is  found  to  consist  of 
fibroid  material,  with  small  areas  of  interspersed  caseation. 
The  condition  is  a  very  rare  one,  and  we  remember  to  have 
seen  only  one  example,  which  was  probably  of  this  nature. 

Symptoms.— The  symptoms  of  acute  dry  pleurisy  set  in  as 
a  rule  somewhat  suddenly.  The  patient  complains  of  cough 
and  pain  in  the  side,  increased  on  deep  breathing.  The  tem- 
perature is  found  to  be  somewhat  raised,  reaching  perhaps 
100°  or  101°.  The  percussion  note  is  natural,  and  the  breath- 
sounds  vesicular,  though  weak  and  uneven.  The  diagnosis 
depends  upon  the  detection  of  a  friction  sound,  the  charac- 
teristics of  which  have  been  already  described  (see  p.  6q). 
This  is  heard  over  the  seat  of  pain,  generally  in  the  lower 
posterior  or  lateral  regions  of  the  chest.  The  disease  gener- 
ally lasts  but  a  few  days,  when  the  temperature  falls  and 
the  friction  sound  disappears.  If  the  pleurisy  be  secondary 
to  some  other  disease,  such  as  pneumonia,  pulmonary  infarct, 
phthisis,  or  gangrene,  its  symptoms  will  merge  into  those 
of  the  primary  disease,  but,  as  a  rule,  some  pain  in  the  side 
(in  pneumonia  often  of  great  severity)  will  be  complained  of, 
and  a  friction  sound  is  generally  detected. 

Diaphragmatic  Pleurisy. — When  the  pleurisy  is  restricted  to 
the  surface  of  the  diaphragm,  the  symptoms  present  certain 
peculiarities.  The  onset  of  the  disease  is  marked  by  severe 
pain  in  the  lower  portion  of  the  chest  corresponding  to  the 
insertion  of  the  diaphragm.  The  pain,  as  Gueneau  de  Mussy 
pointed  out,  is  especially  felt  along  the  tenth  rib,  extending 
from  the  anterior  extremity  to  the  sternum  and  ensiform 
cartilage.  Sometimes  it  radiates  to  the  back  and  shoulders. 
The  hypochondrium  is  tender  on  pressure.  Respiration  is 
hurried,  but  the  diaphragm  on  the  affected  side  is  kept  motion- 
less, since  every  contraction  aggravates  the  pain.  The  patient 
is  feverish,  and  looks  ill  and  anxious,  but  a  careful  physical 
examination  at  first  reveals  nothing  to  account  for  the  some- 
what alarming  symptoms,  which  may  after  a  short  time 
decline,  and  recovery  take  place.  If  effusion  follows,  the 
characteristic  signs  will  suggest  the  true  nature  of  the  disease. 
It  is  easy  for  the  physical  signs  of  diaphragmatic  pleurisy  to 
be  overlooked,  and  in  purulent  cases  the  diagnosis  may  be 
made  only  on  a  sudden  discharge  of  pus  through  the  lung. 


DISEASES   OF   THE   PLEURA  .  89 

We  must  add  that,  though  the  disease  generally  manifests 
itself  by  severe  symptoms,  it  may  be  masked  by  the  other 
conditions  present.  We  have  seen  a  case  of  phthisis  in  which 
the  autopsy  revealed  a  tuberculous  diaphragmatic  empyema 
containing-  half  a  pint  of  pus,  although  during  life  there  had 
been  no  symptoms  to  suggest  the  presence  of  such  a  com- 
plication. 

For  the  points  which  should  be  attended  to  in  forming  a 
diagnosis  between  pleurisy,  intercostal  neuralgia  and  rheu- 
matism we  must  refer  the  reader  to  what  we  have  already 
said  upon  the  subject  (see  p.  81). 

Treatment. — In  many  cases  of  dry  pleurisy  immediate  relief 
is  given  by  firmly  strapping  the  affected  side,  so  as  to  restrain 
its  movement,  as  first  recommended  by  the  late  Dr.  Roberts. 
A  useful  clinical  test  as  to  the  amount  of  relief  which  may 
be  thus  expected  is  obtained  by  observing  the  effect  of 
steady  and  firm  pressure  by  the  hand  upon  the  affected  side. 
In  some  cases  strapping  cannot  be  borne,  either  on  account 
of  its  increasing  the  pain  or  from  the  fact  that,  as  may  happen 
in  phthisis,  the  pleurisy  has  supervened  on  the  side  most 
available  for  respiration.  Under  such  circumstances  the 
application  of  a  small  blister,  with  or  without  a  hot  linseed 
poultice  superposed,  will  give  relief  or,  if  the  pain  be  severe, 
three  or  four  leeches  may  be  applied.  In  cases  associated 
with  pneumonia  the  latter  remedy  is  of  great  value.  An 
opiate  or  subcutaneous  injection  of  morphia  may  be  em- 
ployed if  necessary,  simultaneously  with  one  or  other  of  the 
above  remedies. 

REFERENCES. 

'  "  Systeme  Lymphatique,"  par  P.  Poirier  et  B.  Cuneo,  Traite  d^AnatoViie 
Humaine,  par  P.  Poirier  et  A.  Charpy,  tome  ii.,  p.  1245.      Paris,  1909. 

^  The  Extant  Works  of  Aretceus  the  Ca-p-padocian,  edited  and  translated 
by  Francis  Adams,  LL.D.,  "  On  the  Causes  and  Symptoms  of  Acute 
Diseases,"  book  i.,  chap,  x.,  p.  255.     London,  1856. 

^  "  Case  of  Chronic  Tubercular  Disease  of  the  Lungs,  illustrating  one 
Mode  of  Production  of  Thickening  of  the  Pleura,"  by  R.  Douglas  Powell, 
M.D.,  Transactions  of  the  Pathological  Society  of  London,  1868-69,  ^'^^-  ^^'-i 
P-  59- 

^  "  Tuberculous  Pleurisy,"  being  the  Shattuck  Lecture  of  the  Massa- 
chusetts Medical  Society.  By  William  Osier,  M.D.  Boston,  1893. 
(See  "  Collected  Reprints,"  Third  Series,  by  William  Osier,  M.D.) 


CHAPTER  VII 

SERO-FIBRINOUS  AND  HEMORRHAGIC  PLEURISY 

Acute   Sero-Fibrinous   Pleurisy. 

Sero-fibrinous  pleurisy  does  not  differ  in  its  early  stages 
from  the  acute  dry  pleurisy  just  considered.  The  pleural 
surfaces  are  inflamed  and  lymph  is  exuded;  but  whereas  in 
dry  pleurisy  this  constitutes  the  whole  disease,  in  the  variety 
now  under  consideration  there  is,  in  addition,  an  effusion  of 
fluid,  for  the  most  part  serous  in  nature,  and  sometimes 
amounting-  to  many  pints  in  quantity. 

.etiology. — This  disease  may  occur  in  the  course  of  other 
maladies,  such  as  phthisis,  rheumatic  fever  or  pneumonia. 
In  these  cases  the  pleurisy  Avould  seem  to  depend  upon  the 
agency  of  the  micro-organism  which  has  produced  the 
original  disease.  When  occurring  in  association  with  malig- 
nant disease  of  the  lung,  effusions  into  the  pleura  are  due 
perhaps  as  often  to  obstruction  of  bloodvessels  and  lym- 
phatics as  to  definite  inflammation  of  the  serous  membrane. 
Pleurisy,  in  common  with  other  serous  inflammations,  also 
occurs  in  the  course  of  acute  and  chronic  Bright's  disease, 
but  the  effusion  into  the  pleura  met  with  in  this  disease  is 
more  frequently  of  a  passive  nature. 

Concerning  the  primary  cases,  in  which  the  pleurisy  appar- 
ently arises  de  novo,  and  which  constitute  the  bulk  of  all 
sero-fibrinous  effusions,  it  was  held  until  recently  that  expo- 
sure to  cold  or  draught  was  the  chief  factor  in  their  causation, 
whence  the  term  picuritis  a  frigore.  This  view  we  now  know 
to  be  incorrect,  and  no  doubt  the  great  majority  of  such 
cases  are  really  tuberculous  in  nature.  In  certain  instances, 
however,  a  pleurisy  which  to  the  naked  eye  appears  serous  in 
character,  though  the  microscope  will,  as  a  rule,  show  excess 
of  polymorphonuclear  leucocytes  in  the  fluid,  is  due  to  the 

9P 


SERO-FIBRINOUS   AND   HEMORRHAGIC   PLEURISY  QI 

presence  of  the  pneumococcus  or,  as  in  the  recent  influenza 
epidemic,  to  the  streptococcus,  although  in  most  cases  these 
give  rise  to  a  suppurative  pleurisy. 

The  evidence  upon  which  is  based  our  belief  as  to  the  tuber- 
culous nature  of  most  primary  serous  effusions  may  be  sum- 
marised as  follows : 

(i)  If  we  trace  the  after-history  of  these  cases,  we  see  that 
in  many  of  them  apparent  recovery  is  shortly  followed  by 
the  development  of  phthisis;  thus.  Dr.  Hedges,^  following  up 
130  cases  from  St.  Bartholomew's  Hospital,  found  that  within 
six  years  or  less  "43  per  cent,  had  either  died  of  phthisis  or 
other  tubercular  lesion,  or  presented  signs  of  the  former 
disease."  Very  similar  results  were  obtained  by  Dr.  Barrs,^ 
and  more  recently  by  two  Swedish  observers,  Drs.  Allard 
and  Koster.^  The  conclusion,  therefore,  that  the  pleurisy 
in  these  cases  was  in  reality  tuberculous  from  the  first  is 
strongly  suggested,  and  is  further  strengthened  by  the  fact 
that  in  certain  rare  cases,  such  as  those  recorded  by  Kelsch 
and  Vaillard,*  in  which  the  patients  died,  tubercles  have  been 
found  in  the  serous  membrane. 

(2)  An  examination  of  the  fluid  by  staining  methods  affords 
confirmatory  evidence.  If  the  fluid  withdrawn  by  aspiration 
be  examined  without  special  preparation,  bacilli  are  as  a  rule 
not  found.  If,  however,  we  follow  Dr.  Jousset's^  method, 
and  allow  the  fluid  to  clot,  then  digest  the  clot  with  artificial 
gastric  juice,  and  finally  stain  films  made  from  the  centri- 
fugalised  liquid,  tubercle  bacilli  can  often  be  detected.  Jousset 
himself  claimed  to  have  demonstrated  them  in  seventeen 
successive  cases  of  primary  serous  pleurisies. 

(3)  Inoculation  experiments  tell  a  similar  tale,  provided 
large  enough  quantities  of  fluid  be  injected.  Netter*^  found 
that  in  eight  cases  out  of  twenty  of  primary  sero-fibrinous 
pleurisy  he  was  able  to  induce  tuberculosis  in  guinea-pigs  by 
injecting  into-  the  peritoneal  cavity  i  to  i|  c.c.  of  the  fluid 
withdrawn  by  aspiration.  Eichhorst,''  using  a  larger  quantity 
(15  c.c),  produced  tuberculosis  in  65  per  cent,  of  his  cases; 
while  Le  Damany,'  by  injecting  10  to  50  c.c,  and  in  one  case 
even  300  c.c,  was  successful  in  forty-seven  out  of  fifty-five 
cases,  or  85  per  cent. 

These  statements  are  not  gainsaid,  and  we  are  driven, 
therefore,  to  the  conclusion  that  by  far  the  greater  number 


92 


DISEASES    OF   THE   LUNGS   AND    PLEURAE 


of  cases  of  primary  sero-fibrinous  pleurisy  are  in  reality 
tuberculous  in  nature — a  fact  which  must  greatly  influence 
our  after-treatment  of  the  malady. 

Morbid  Anatomy — Nature  of  the  Fluid. — As  we  have  seen, 
the  morbid  changes  are  at  first  similar  to  those  observed  in 
the  plastic  or  dry  variety  of  the  disease.  Hyperaemia  first 
occurs,  to  be  followed  shortly  by  roughening  of  the  surface 
and  the  deposition  of  lymph.  Effusion,  however,  then  takes 
place,  which,  as  it  increases,  separates  the  surfaces  more  or 
less  widely  from  each  other.  The  fluid  thus  effused  is  clear, 
yellowish  in  colour,  from  the  presence  of  serum-lutein,  and 
alkaline  in  reaction.  It  is  highly  albuminous,  and  on  stand- 
ing undergoes  spontaneous  coagulation;  but  the  amount  of 
fibrin  which  separates  out  is  never  great.  On  microscopical 
examination,  leucocytes  are  seen,  also  a  few  large  cells, 
derived  from  the  endothelium  lining  the  pleural  surface, 
together  with  a  fair  number  of  red  corpuscles.  The  leuco- 
cytes, as  Widal  and  Ravaut'  were  the  first  to  show,  are  mostly 
small  mononuclears,  and  so  constant  is  their  presence  in 
great  excess  in  cases  of  tuberculous  pleurisy,"  except  in  its 
earliest  stage,  that  a  cytological  examination  will  be  found  of 
value  when  considering  the  diagnosis  of  any  case.  It  should 
be  stated,  however,  that  in  cases  of  malignant  pleurisy  a 
similar  excess  of  small  mononuclears  is  often  to  be  observed.* 

According  to  Professor  Halliburton,'^  whose  researches 
have  been  confirmed  by  other  observers,  the  average  chemi- 
cal composition  of  the  fluid  may  be  given  as  follows,  the 
corresponding  figures  for  passive  effusions  (chronic  renal 
and  heart  disease)  being  quoted  for  comparison  ; 


Specific 
Gravity. 

Total 
Proteids 
per  Cent. 

Fibrin. 

Serum 
Globulin. 

Serum 
Albumin. 

Acute  pleurisy         ...        1021 
Hydrothorax           ...        1014 

1 

4  "5903 

17748 

o'0473 
o-oo86 

2-0007 
06138 

2-2II2 

1-1558 

*  If  the  fluid,  after  withdrawal  from  the  chest,  cannot  be  at  once 
examined  by  the  pathologist,  it  is  well  to  add  one-quarter  its  volume  of 
a  citrate  solution  of  the  following  composition  : 

Sodium  citrate  ...  ...  ...  ...       1-5  grms. 

Sodium  chloride  ...  ...  ...  ...       0-85  grms. 

Distilled  water  ...  ...  ...  ...       100  c.c. 

In  this  way  clotting  is  prevented  and  the  cells  are  preserved- 


SERO-FIBRINOUS   AND    HEMORRHAGIC   PLEURISY  93 

From  these  figures  it  will  be  seen  that  in  acute  sero-fibrinous 
pleurisy  the  fluid  is  of  higher  specific  gravity  and  richer  in 
proteids  than  in  non-inflammatory  effusions,  whilst  the  yield 
of  fibrin  is  also  greater,  leading  to  more  rapid  coagulation  of 
the  fluid.  The  proportion  of  serum  albumin  to  serum 
globulin  is  variable,  and  possesses  no  clinical  importance. 

In  cases  of  chronic  pleurisy,  according  to  the  analysis  of 
Mehu,'-  the  fluid  would  seem  more  closely  to  resemble  that 
of  hydrothorax. 

Symptomatology. — The  following  description  of  the  disease 
will  apply  chiefly  to  the  common  primary  variety,  the  pleuritis 
a  frigore  of  older  writers;  but  the  symptoms  and  physical 
signs  of  cases  complicating  other  diseases  do  not  differ  in 
any  essential  particular. 

The  symptoms  and  signs  of  sero-fibrinous  pleurisy  are  in 
accordance  with  its  pathology,  and  are  divided  into  three 
stages  :  (i)  the  stage  of  hyperaemia  and  commencing  exuda- 
tion; (2)  the  stage  of  effusion;  (3)  the  stage  of  absorption 
and  convalescence. 

Pains  in  the  side  and  shivering  are  the  two  symptoms 
which  usher  in  the  attack,  and  either  may  precede  the  other 
by  a  few  hours.  The  pain  is  that  of  an  acute  "  stitch "  in 
the  side,  usually  felt  in  the  lower  axillary  or  inframammary 
region,  but  sometimes  referred,  and  especially  in  children,  to 
a  much  lower  point  in  the  abdominal  wall  to  which  the  ter- 
minal cutaneous  twigs  of  the  aft"ected  intercostal  nerves  are 
distributed.  The  pain  interferes  with  the  respiratory  move- 
ments, which  are  restrained  and  shallow,  the  patient  inclin- 
ing to  the  affected  side  so  as  to  lessen  its  movement.  The 
shivering  is  of  variable  severity,  sometimes  very  sharp  and 
decided — a  true  rigor — at  other  times  amounting  only  to 
recurring  chills.  It  is  stated  that  the  rigors  of  pleurisy  are 
repeated,  whilst  in  pneumonia  one  severe  shivering  occurs  at 
the  commencement  of  the  disease;  but  in  neither  case  is  this 
statement  more  than  generally  speaking  correct.  There  is 
occasional  dry,  interrupted  cough.  The  temperature  as  a  rule 
rises  rapidly  to  about  102°  or  103°  (see  Figs.  17  and  18),  the  face 
is  anxious  and  pale,  the  pulse  small  and  moderately  frequent. 
The  fever  has  never  the  marked  character  of  that  of  pneu- 
monia, and  the  flushed  cheek  and  burning  skin  so  charac- 
teristic of  the  latter  disease  are  rarely  present.     In  a  word, 


94 


DISEASES   OF   THE   LUNGS   AND   PLEUR/E 


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96  DISEASES   OF   THE   LUNGS   AND   PLEURA 

the  patient  with  acute  pleurisy  is  not  so  ill  as  one  with  pneu- 
monia, although  he  may  be  in  more  suffering. 

In  the  first  stage  of  the  disease  there  is  no  percussion  dul- 
ness.  On  hstening  to  the  chest,  the  respiratory  murmur  will 
be  found  to  be  uneven  and  partially  suppressed  on  the  affected 
side,  and  a  more  or  less  distinct  friction  sound,  usually  of  a 
grating  character,  will  be  heard.  This  is  most  distinct  at  the 
end  of  inspiration  and  the  beginning  of  expiration,  and.  is 
best  heard  over  the  seat  of  pain,  usually  in  the  mammary  or 
inframammary  region,  or  over  the  base  of  the  lung.  In 
left-sided  cases  friction  of  cardiac  rhythm — the  so-called 
pleuro-pericardial  friction  (see  p.  60) — may  be  heard  over  the 
region  of  the  heart.  Friction  fremitus  is  occasionally  .  to 
be  felt.  In  some  cases,  however,  which  present  all  the 
symptoms  and  febrile  phenomena  characteristic  of  pleurisy, 
no  friction  sound  can  be  heard.  This  may  be  explained  by 
the  manner  in  which  the  affected  side  of  the  chest  is  held 
fixed  by  the  patient,  or  by  the  pleuritic  exudation  commenc- 
ing on  the  diaphragmatic  or  mediastinal  aspect  of  the  pleura, 
and  thus  being  beyond  the  reach  of  appreciation  by  the 
stethoscope. 

Within  a  short  time — it  may  be  but  a  few  hours — fluid  com- 
mences to  be  effused,  and  dulness  may  be  detected  at  the 
extreme  base  posteriorly,  gradually  extending  upwards 
towards  the  apex.  With  the  occurrence  of  effusion  the  pain 
becomes  less,  the  breathing  easier  and  less  catching,  although 
quicker  than  natural.  The  movements  of  the  affected  side 
are  notably  lessened,  and  the  respiratory  sounds  more  or 
less  effaced,  in  marked  contrast  to  their  exaggerated  inten- 
sity on  the  sound  side.  In  moderate  degrees  of  effusion,  and 
especially  in  the  early  stages  before  adhesions  have  had 
time  to  form,  the  dulness  varies  slightly  with  the  position  of 
the  patient;  when  lying  down,  for  instance,  the  resonance 
may  be  good  to  just  below  the  nipple,  whereas  on  sitting  up 
there  is  dulness  up  to  the  nipple,  and  it  may  be  higher.  As 
the  fluid  increases,  the  respiratory  murmur  soon  becomes 
diminished  or  inaudible  over  the  lower  portion  of  the  dull 
area,  and  friction  can  here  no  longer  be  detected.  Too  much 
importance  must  not,  however,  be  attached  to  auscultatory 
evidence  in  the  diagnosis  of  pleuritic  effusion.  As  the  upper 
limits   of  dulness  are  approached,   distant  tubular  breathing 


SERO-FIBRINOUS   AND   HEMORRHAGIC   PLEURISY  97 

may  be  heard  in  the  scapular  region,  whilst  friction  sound 
of  a  moister  character  is  often  audible,  especially  in  front. 
With  the  advance  of  the  effusion  the  breathing-  becomes 
increasingly  distressed,  and  may  amount  even  to  orthnopnoea. 

The  signs  of  pleuritic  effusion  may  be  divided  into  three 
groups : 

{A)  The  cardinal  signs  of  pleuritic  effusion,  the  presence 
of  which  are  alone  essential  for  diag'nosis — viz.  (i)  percussion 
dulness;  (2)  displacement  of  the  heart;  (3)  annulled  vocal 
fremitus;  (4)  diminished  and  altered  or  absent  breath-sound. 
These  signs  are  common  to  all  varieties  of  effusion,  whether 
serous,  purulent  or  hasmorrhagic. 

(B)  Subordinate  or  supplementary  signs — viz.  (i)  alteration 


Fig.  19. — Percussion  Signs  in  Case  of  Moderate  Effusion. 

A,  area  of  complete  dulness  ("flatness");  B,  area  of  tympanitic  (skodaic) 
resonance ;  C,  inferior  curved  line  of  tympanitic  (stomach)  resonance. 

in  shape  of  chest  and  increase  in  semi-circumference;  (2) 
intercostal  bulging,  elasticity,  or  fluctuation;  (3)  skodaic 
resonance;  (4)  altered  voice-sound;  (5)  displacement  of 
^  abdominal  viscera;  (6)  signs  in  the  other  lung;  and  (7)  car- 
diac displacement  bruits.  These  signs  are  none  -of  them 
essential  for  diagnosis,  and  any  or  all  of  them  may  be 
wanting. 

(C)  Signs  indicative  of  the  nature  of  the  fluid — viz.  (i) 
temperature  signs ;  (2)  other  pyrexial  or  septic  phenomena ; 
(3)  pectoriloquie  aphonique  (Baccelli) ;  (4)  the  result  of 
exploratory  puncture. 

I.  The  dulness  of  effusion  is  absolute  and  toneless.     It  is 

7 


98  DISEASES   OF   THE   LUNGS   AND   PLEUR^^L 

distinguished  by  our  American  confreres  from  more  ordinary 
degrees  of  dulness  by  the  term  "  flatness."  It  is  the  duhiess 
of  a  brick  wall  rather  than  that  of  a  table.  In  ascertaining 
the  limits  of  dulness  in  cases  of  effusion,  very  light  percus- 
sion should  be  employed,  or  the  resonance  of  neighbouring 
parts  will  be  elicited. 

In  cases  of  moderate  effusion,  in  which  the  lung  is  tex- 
turally  healthy,  the  upper  margin  of  dulness  in  front  is  not  a 
level  line,  but  slants  downwards  and  inwards  in  such  a 
manner  as  to  leave  a  somewhat  triangular  space  of  resonance 
(B,  Fig-.  19),  the  apex  of  the  triangle  being  at  the  sterno- 
clavicular articulation.     The  resonance  within  this  area  is  of 


Fig.  20. — Percussion  Signs  in  Case  of  Moderate  Effusion. 

A,    area    of    complete    dulness  ("flatness");    B,    pulmonary    note    usually 
impaired ;  C,  more  or  less  tympanitic  high-pitched  resonance. 

a  peculiar  tympanitic  quality,  termed  "  skodaic  resonance," 
to  which  we  shall  again  refer.  The  line  of  dulness  (flatness) 
is  highest  in  the  axilla,  and  extends  round  to  the  scapula  until 
in  the  interscapular  region  it  again  slants  downwards,  a 
tongue  of  comparative  resonance  protruding  downwards  in 
the  postero-medjan  line  (B,  Fig.  20).  This  curved  line,  which 
marks  the  upper  limit  of  dulness,  is  sometimes  spoken  of  as 
"Damoiseau's  curve,"  or  the  "letter  S  curve  of  Ellis,""  and 
is  in  sharp  contrast  to  the  horizontal  upper  Hmit  in  cases  in 
which  air  as  well  as  fluid  is  present  in  the  pleural  cavity.  The 
lower  lim_it  of  dulness  is  again  peculiar,  the  arch  of  the 
diaphragm   being   preserved    (see    Fig.    19),    even   when    the 


SERO-FIBRINOUS   AND   HEMORRHAGIC   PLEURISY  99 

amount  of  fluid  is  large,  so  long,  indeed,  as  skodaic  resonance 
is  manifested.  This  can  be  best  observed  in  left-sided  cases, 
and  to  it  we  shall  again  allude. 

Even  in  cases  in  v^hich  the  effusion  is  very  considerable  and 
of  old  standing,  a  triangular  area  of  comparative  resonance 
(but  now  somewhat  tubular  in  quality)  can  still  be  made  out 
at  the  sterno-clavicular  angle,  and  also  in  the  upper  inter- 
scapular region.  In  cases  of  extreme  effusion,  however,  the 
"flatness"  of  the  percussion  note  extends  throughout  the 
utmost  limits  of  the  thorax,  and  these  triangles  of  resonance 
are  no  longer  to  be  found.  In  other  cases,  again,  oedema  or 
consolidation  of  the  lung  may  obscure  the  signs  over  the 
areas  referred  to.  As  the  fluid  increases,  the  dulness 
encroaches  upon  the  median  line,  extending  farthest  across 
at  the  level  of  the  third  and  fourth  cartilages,  where  it  merges 
into  the  dulness  of  the  displaced  heart  (D,  Fig.  19). 

2.  Displacement  of  heart  towards  the  sound  side  is  the 
second  cardinal  sign  of  pleuritic  effusion.  The  absence  of 
this  sign  would  negative  the  diagnosis  of  unilateral  effusion, 
unless  it  were  explained  by  special  circumstances,  such  as 
fixation  of  the  pericardium  by  old  adhesions  or  consolidation 
of  the  opposite  lung,  the  result  of  some  former  disease.  But 
such  cases  are  rarely  met  with,  and  the  mediastinal  folds  are 
ready  to  shift  to  one  side  or  the  other,  as  the  pleura  becomes 
occupied  and  the  lung  on  that  side  collapsed,  leaving  un- 
opposed the  traction  of  the  other  lung  upon  the  mediastinum. 
Displacement  of  the  heart  as  a  sign  of  pleuritic  effusion  is 
of  much  greater  value  than  displacement  of  other  organs, 
because  it  takes  place  immediately  and  pari  passu  with  the 
effusion.  In  this  respect  it  strikingly  differs  from  displace- 
ment of  the  diaphragm  and  abdominal  viscera.  The  dia- 
phragm is  held  up  in  the  arched  position  until  the  effusion 
has  mounted  to  a  considerable  height  and  the  heart  has 
already  markedly  retreated  towards  the  opposite  side.  Con- 
sequently, displacement  of  abdominal  viscera  is  no  essential 
sign  of  pleuritic  effusion,  and  is  only  present  in  extreme 
cases;  displacement  of  heart,  on  the  other  hand,  is  an  essen- 
tial sign,  and  (unless  prevented  by  countervaihng  causes)  is 
present  from  the  first  in  all  cases  of  unilateral  effusion. 

Although  the  exact  position  of  the  heart  is  often  somewhat 
difficult  to  make  out,  the  trouble  taken  is  well  rewarded  by 


lOO  DISEASES   OF   THE   LUNGS   AND   PLEURA 

the  importance  of  the  sign.  The  position  of  the  apex-beat 
should  be  carefully  felt  for  by  the  hand,  and,  if  necessary,  by 
the  ear  through  the  medium  of  the  stethoscope.  Percussion 
may  also  be  usefully  employed  to  trace  from  the  sound  side 
the  line  of  cardiac  dulness.*  The  axis  of  the  heart  is  not 
greatly  changed  in  direction  by  any  common  degree  of  effu- 
sion. It  becomes  a  little  more  vertical,  and  in  very  extreme 
cases  it  may  even  be  slightly  twisted;  but  we  have  never 
seen,  nor  been  able  to  produce  by  experiment,"  anything 
approaching  to  the  complete  turnover  of  the  heart,  which 
has  been  stated  to  occur  in  extreme  effusion.  In  cases  in 
Avhich  the  heart  is  greatly  displaced  a  systoHc  murmur  is 
developed  over  its  base,  which  disappears  on  removal  of  a 
portion  of  the  fluid,  and  is  presumably  due  to  straightening 
of  or  slight  traction  upon  the  great  vessels  from  pressure 
of  the  fluid. 

3.  Absence  of  vocal  fremitus  is  a  third  very  important  sign 
of  pleuritic  effusion.  It  is  obviously  due  to  the  intervention 
of  a  bad  conductor  of  such  vibrations  between  the  vibrating 
media  and  the  chest  walls,  and,  if  these  two  be  united  at  any 
point  by  a  cord  of  adhesion,  the  fremitus  may  there  be  felt. 
Just  as  light  percussion  is  needed  to  define  the  exact  limits 
of  dulness,  so  lig"ht  palpation  is  necessary,  employing  the 
finger-tips  rather  than  the  whole  hand,  in  order  better  to 
exclude  vibrations  from  above  as  the  confines  of  the  effusion 
are  approached.  With  the  same  object  the  edge  of  one  hand 
may  be  placed  along  the  upper  Hmit  of  dulness,  whilst  the 
other  hand  is  employed  in  palpation  below. 

It  will  thus  be  observed  that  the  three  most  essential  signs 
of  pleuritic  effusion  are  ehcited  by  palpation  and  percussion. 
4.  The  stethoscopic  signs  in  pleuritic  effusions  are  of  less 
importance,  and  are  sometimes  misleading.  A  certain  value 
is  justly  attached  to  the  diminished  breath-sounds,  and,  except 
towards  the  upper  confines  of  the  effusion,  to  the  diminished 
voice-sounds,  in  the  diagnosis  of  pleuritic  effusion,  but  in  not 
a  few  cases  of  this  disease  the  breath-sounds  are  audible  over 

*  There  is  one  fallacy  with  reference  to  cardiac  displacement  in  the 
earlier  stages  of  effusion  that  may  be  here  noted — viz.,  that  as  the  base  of 
the  lung  retracts,  the  right  or  left  margin  of  the  heart  (as  the  case  may  be 
right-  or  left-sided)  becomes  uncovered  :  this  may  lead  to  an  apparent 
delay  in  the  displacement  of  the  organ,  the  extreme  right  or  left  margin 
thus  being  within  reach  of  palpation. 


SERO-FIBRINOUS   AND   HEMORRHAGIC   PLEURISY         lOI 

the  whole  side,  well  defined,  bronchial,  and  not  easily  dis- 
tinguished from  the  breath-sounds  of  pneumonia.  This  is 
especially  the  case  in  children.  The  voice-sounds  may  also 
be  well  conducted  over  the  whole  side,  and  the  whisper 
exaggerated  even  to  pectoriloquy.  As  an  instance  we  may 
quote  the  case  of  a  boy  aged  eleven  years,  who  came  under 
the  care  of  one  of  us  at  the  Middlesex  Hospital  with  acute 
pleurisy  and  effusion  on  the  right  side,  of  four  days'  duration. 
On  the  fifth  day  after  admission  the  dulness  had  extended  to 
the  clavicle  and  well  over  the  median  line.  The  vocal 
fremitus  was  annulled,  the  heart  was  beating  considerably 
outside  the  left  nipple  line,  and  the  cyrtometer  tracing  showed 
enlargement  of  the  affected  side;  but  bronchial  breath-sound 
and  whispering  pectoriloquy  could  be  well  heard  posteriorly 
to  the  base,  and  somewhat  more  feebly  over  the  lower  two- 
thirds  anteriorly.  It  was  difficult  to  believe  that  one  was 
listening  over  an  immovably  compressed  lung,  separated 
from  the  ear  by  some  inches  of  fluid.  Twenty-six  ounces  of 
clear  serum  were,  however,  readily  removed  the  next  day, 
with  great  relief  to  the  little  patient. 

The  reason  why  we  should  thus  have  very  weak  or  absent 
breath-sounds  in  some  cases  and  in  others  bronchial  breath- 
ing demands  a  few  moments'  consideration.  The  weakening 
of  the  vesicular  murmur  is  usually  attributed  to  the  inter- 
position of  a  badly  conducting  layer  of  fluid  between  the  lung 
and  chest  wall,  and  in  shght  cases  this  may  be  sufficient  to 
explain  the  facts.  But  it  must  be  remembered  that  fluid  is 
by  no  means  devoid  of  conducting  power,  as  was  shown,  for 
example,  in  a  case  of  left-sided  pleural  effusion  under  our 
care  at  the  Brompton  Hospital,  in  which  an  endocardial 
mitral  murmur  was  well  heard  through  the  fluid  below  the 
angle  of  the  left  scapula,  as  well  conducted  as  through  lung. 
The  presence  of  fluid  alone,  therefore,  cannot  be  held  to 
explain  total  absence  of  respiratory  murmur,  and  it  is 
probable  that — in  some  cases,  at  least — this  is  attributable  to 
attendant  bronchitis  leading  to  partial  or  complete  occlusion 
of  the  bronchi  by  accumulation  of  mucus.  The  bronchial 
breath-sound  when  heard  would  seem  to  be  due  to  the  com- 
plete collapse  of  that  portion  of  the  lung  auscultated,  and  the 
total  elimination  of  its  vesicular  element.  As  a  result,  the 
laryngeal    breath-sounds,    provided    the    bronchi    are    patent, 


102  DISEASES   OF   THE   LUNGS   AND   PLEURA 

are  conducted  unaltered  through  the  fluid  to  the  chest  wall, 
some  of  their  intensity  being  indeed  lost  during  the  process, 
but  their  special  character  remaining  unimpaired. 

Supplementary  Signs  of  Effusion— Much  importance  is 
usually  attached  to  increase  in  the  semi-circumference  of  the 
chest  as  a  sign  of  pleural  effusion.  This  is  more  apparent 
than  real,  and  is  chiefly  noticeable  during  expiration,  from 
the  comparative  absence  of  recession  on  the  affected  side. 
Should  the  effusion  be  considerable,  the  actual  semi-circum- 
ference of  the  chest  on  the  affected  side  will  be  augmented, 
and  in  any  case  in  which  a  decidedly  increased  measurement 
is  obtained  we  may  be  sure  that  the  exudation  is  a  large  one. 
The  total  circumference  of  the  chest  must  in  any  case  of 
effusion  be  increased  from  the  elastic  outspring  of  the  ribs. 

Cyrtometer  tracings  give  us  more  information  than  tape 
measurements,  since  they  also  take  into  account  an  altered 
shape,  but,  except  for  recording  purposes,  inspection  with 
the  unaided  eye  is  more  useful  than  either. 

Intercostal  fulness  or  fluctuation  is  a  sign  of  exceptional 
occurrence  in  cases  of  effusion,  intrathoracic  pressure  alone, 
except  in  very  extreme  cases,  being  insufficient  to  cause  it. 
It  is  more  commonly  present  in  children  than  adults,  and 
especially  in  weakly  children  with  wasted  muscles.  A  certain 
degree  of  laxity  or  inflammatory  softening  of  the  thoracic 
parietes  is  needed  for  the  presence  of  this  sign,  which  in  our 
experience  is  more  often  associated  with  purulent  than  with 
serous  effusion." 

JEgophony  is  a  sign  commonly  met  with  in  pleuritic  effu- 
sions, but,  as  we  have  pointed  out,  may  be  sometimes  also 
heard  over  consolidated  lung  (see  p.  6i).  It  will  often  be 
observed  on  listening  for  segophony  in  cases  of  acute  effusion 
that  a  certain  lisp  attends  the  voice-sound,  which  lisp  is  more 
sharply  conducted  than  the  aegophonic  sound.  In  such  cases, 
if  the  whispered  voice  be  listened  to,  it  will  be  found  to  be 
very  distinctly  conducted  through  the  fluid  (Baccelli's  sign, 
see  p.  120). 

Pressure  Signs. — It  has  been  already  pointed  out  that, 
whereas  cardiac  displacement  is  an  essential  sign  of  effusion, 
it  is  no  evidence  of  intrathoracic  pressure.  Displacement 
downwards  of  the  diaphragm  is,  on  the  other  hand,  always  a 
sign  of  intrapleural  pressure.     The  relationship  of  the  dia- 


SERO-FIBRINOUS    AND   HEMORRHAGIC   PLEURISY         IO3 

phragm  to  the  cavities  above  and  below  it  is  quite  a  different 
one  to  that  which  the  mediastinum  bears  to  the  pleura  on 
either  side.  We  have  on  the  thoracic  side  of  the  diaphragm, 
under  normal  conditions,  a  negative  pressure;  on  the 
abdominal  side  the  prevailing  pressure  is  positive.  The  nega- 
tive pressure  within  the  pleura  is  maintained  until  the  lung 
has  completely  retracted  before  the  advancing  fluid;  after  this 
point  any  further  accumulation  compresses  the  lung,  and  by 
its  weight  and  pressure  forces  down  the  diaphragm.  Hence 
displacement  downwards  of  the  abdominal  viscera  is  a  late 
phenomenon  in  pleuritic  effusion.  It  also  varies  according 
as  the  patient  has  been  keeping  about,  or  has  remained  in 
bed,  and  it  is  more  often  met  with  in  purulent  than  in  serous 
cases. 

The  clinical  outcome  of  these  observations  in  regard  to  the 
displacement  of  the  diaphragm  is  of  great  practical  im- 
portance. As  was  first  pointed  out  by  Traube,  and  more  fully 
explained  in  an  admirable  monograph  by  Dr.  Garland,'*^  of 
Boston,  stomach  note  may  be  obtained  at  the  sixth  rib  in  the 
nipple  line  in  the  presence  of  a  large  effusion  on  that  side. 
Similarly,  on  the  opposite  side,  under  the  same  conditions, 
the  liver  dulness  may  not  be  appreciably  lowered.  These 
facts  are  to  be  borne  in  mind  in  choosing  the  spot  for  para- 
centesis, otherwise  awkward  accidents  may  occur. 

The  period  of  effusion  at  which  the  intrathoracic  pressure 
is  converted  from  a  negative  or  zero  to  a  positive  pressure 
upon  the  lung  and  heart  is  marked  clinically  (i)  by  the  dulness 
mounting  up  above  the  third  cartilage  (the  patient  being  in  a 
sitting  posture);  and  (2)  by  the  skodaic  resonance  becoming 
changed  from  the  full  and  clear  tympanitic  note  to  one  of  a 
more  dull  tubular  quality,  and  finally  becoming  extinguished. 

Skodaic  resonance  is  thus  of  some  clinical  value  in  guiding 
us  to  a  judgment  as  to  the  presence  or  absence  of  pressure 
within  the  thorax,  and  the  advisability  or  urgency  of  inter- 
ference by  paracentesis.  Different  views  have  been  held 
respecting  the  mechanism  of  its  production  in  pleuritic  effu- 
sion. But  whether  we  adopt  the  view  of  Skoda  himself  and 
regard  it  as  the  relaxed  lung  note,  due  to  the  recession  of  the 
lung  towards  its  root  as  the  fluid  advances,  and  resembling 
that  of  a  healthy  lung  when  percussed  on  the  post-mortem 
table;  qr  whether  we  accept  one  of  the  other  varied  explana.- 


104  DISEASES   OF   THE   LUNGS   AND   PLEUR/E 

tions  given,  it  would  seem  that  a  slightly  negative,  or  at  least 
a  zero,  pressure  is  essential  for  the  production  of  the  full- 
toned  Skoda  note.     We  often  meet  with  cases  in  a  later  stage 
of  effusion  in  which,  at  or  near  the  sterno-clavicular  angle, 
the  skodaic  resonance  is  succeeded  by  a  tubular  or  amphoric 
quality  of  resonance,  resembling  the  percussion  note  over  a 
considerable  lung  cavity,  or  over  the  cheek  held  on  the  stretch 
with  the  mouth  slightly  open.     This  resonance  is  probably 
produced  by  the  lung  being  collapsed  upon  its  root,  and  thus 
yielding  the  tracheo-bronchial  resonance.     Clinically  it  signi- 
fies a  higher  degree  of  effusion  than  the  true  skodaic  note; 
it  means  that  the  lung  is  not  simply  contracted,  but  collapsed 
by  the  pressure  of  the  advancing  fluid.     In  the  next  degree 
of  effusion  all  resonance  of  whatever  kind  is  everywhere  lost. 
To  the  displacement  murmur  sometimes  heard   over  the 
base  of  the  heart  in  cases  of  intrapleural  pressure  we  have 
already  alluded.     Another   sign   of  more   importance  is  the 
occurrence  of  crepitant  sounds  over  variable  portions  of  the 
sound  lung.     These  congestion  rales  afford  evidence  of  great 
stress  of  circulation  in  the  other  lung,  and  are  associated  with 
a  congestive  cough,  and  a  viscid,  sometimes  blood-streaked 
sputum.     With  the  development  of  such  signs  the  dyspnoea 
becomes   increasingly    urgent,    the    surface    dusky,    and   the 
patient  is  in  imminent  danger  from  syncope. 

It  is  not  usual,  however,  for  the  effusion  to  attain  such 
dangerous  proportions.  In  a  large  number  of  cases  the  area 
of  skodaic  resonance  is  not  encroached  upon,  before  the  tide 
turns  and  absorption  of  the  fluid  commences. 

In  certain  cases  of  pleural  effusion,  as  pointed  out  by 
Grocco,''  an  area  of  dulness  to  percussion — the  so-called  para- 
vertebral triangle  of  dulness— may  be  noted  at  the  posterior 
base  of  the  healthy  lung.  The  apex  of  the  triangle  extends 
from  the  upper  level  of  the  effusion,  whilst  the  sides  are 
formed  by  the  vertebral  spines  and  by  a  line  drawn  from  the 
apex  of  the  triangle  to  the  base  of  the  thorax,  some  one  to 
three  inches  from  the  middle  line.  The  sign  is  not  always 
present,  and  a  similar  area  of  dulness  has  been  observed  in 
certain  cases^  of  pneumonia.  Its  value  appears  to  us  to  have 
been  overestimated. 

The  fever  of  acute  pleurisy  commonly  subsides  in  from  one 
to  three  weeks,  according  to  the  severity  of  the  attack  (see 


SERO-FIBRINOUS    AND   HEMORRHAGIC   PLEURISY         lO^ 

Charts,  pp.  94  and  95).  The  tongue  cleans,  the  appetite  returns, 
and  the  patient  has  only  to  gain  strength  and  to  await  recovery 
from  the  results  of  the  local  inHammation  and  effusion.  In 
favourable  cases  as  the  fluid  becomes  absorbed,  the  lung 
expands  from  above  downwards,  the  pleural  friction  sound 
returns,  and  with  it  usually  some  pleuritic  pain,  although  of 
not  nearly  so  intense  a  character  as  in  the  first  instance. 

Dr.  Gee,  in  his  work  on  Auscultation,  minutely  and  ac- 
curately described  the  physical  signs  and  other  phenomena 
attendant  upon  receding  effusions;  suffice  it  here  to  say  that 
the  respiratory  murmur  slowly  returns,  at  first  in  the  upper 
portion  of  the  chest,  and  the  heart  gradually  resumes  its 
normal  position.  The  absorption  of  the  last  portion  of  fluid 
is  often  considerably  delayed,  and  dulness  and  weak  respira- 
tion may  long  persist  at  the  posterior  bases,  with  impaired 
movement  and  more  or  less  contraction  of  chest.  In  some 
cases,  indeed,  these  signs  may  never  disappear,  the  pleura  at 
the  base  having  become  thickened  and  adherent.  In  rare 
cases  the  fluid  may  show  no  signs  of  becomiing  absorbed, 
and  the  case  may  eventually  become  one  of  chronic  pleural 
effusion  (see  p.  114). 

Diagnosis. — The  diagnosis  of  pleurisy  is  not  attended  with 
any  great  difficulty.  As  regards  pain,  it  may  be  simulated  by 
pleurodynia  or  intercostal  myalgia,  neither  of  which  affections 
is,  however,  attended  with  febrile  phenomena,  nor  with  fric- 
tion sounds,  nor  the  signs  of  effusion.  Pneumonia  is  the 
disease  with  which  acute  sero-fibrinous  pleurisy  is  most  often 
confounded;  and  we  must  observe  that  the  two  may  coexist. 
The  absence  of  rapidly  developing  bronchial  respiration,  with 
bronchophony  and  fine  crepitation,  the  freedom  from  blood- 
stained sputa,  and  the  gradual  effacement  of  respiratory 
sounds  and  of  vocal  fremitus,  together  with  increasing  dis- 
placement of  heart  as  dulness  on  percussion  increases  in 
extent,  render  the  diagnosis  of  pleurisy  with  effusion  certain. 

Other  conditions  which  may  give  signs  somewhat  resem- 
bling those  of  fluid  in  the  pleura  are  collapse  of  the  lung, 
especially  in  children,  basal  phthisis,  bronchiectasis,  new 
growth  and  hydatid  of  the  lung.  The  diagnosis  is  in  each 
case  considered  under  its  respective  heading,  but  we  may  add 
that  in  most  cases  displacement  of  the  heart  to  the  healthy 
side — the  cardinal  sign  of  pleural  effusion — is  wanting.     Only 


I06  DISEASES   OF   THE   LUNGS   AND   PLEURA 

in  rare  instances  and  under  special  conditions  is  the  heart  not 
displaced  in  the  presence  of  acute  pleuritic  effusion. 

The  chief  difficulty  in  diagnosis  is  to  ascertain  the  probable 
nature  of  the  pleurisy,  whether  sero-fibrinous  or  purulent. 
This  subject  we  shall  consider  later  (see  p.  119). 

Prognosis.— The  immediate  prognosis  in  the  great  majority 
of  instances  is  decidedly  good  in  cases  of  acute  sero-fibrinous 
pleurisy,  aUhough  the  outlook  in  regard  to  completeness  of 
recovery  or  otherwise  is  unquestionably  influenced  by  judi- 
cious treatment.  Sometimes  the  initial  symptoms  of  pleurisy 
are  very  brief  and  slight,  becoming  rapidly  obscured  by  effu- 
sion, and  the  true  nature  of  the  case  is  not  recognised;  per- 
haps advice  is  not  even  sought  until  the  breathing  be  notably 
embarrassed  by  a  large  effusion.  In  these  cases  recovery  is 
often  slow  and  imperfect. 

The  danger  of  sudden  death  in  cases  of  acute  pleurisy  with 
effusion  is  but  small.  It  was  exaggerated  by  Trousseau," 
but  is  by  no  means  to  be  left  out  of  consideration,  especially 
in  cases  in  which  the  effusion  reaches  above  the  second  rib — 
i.e.,  in  which  there  is  positive  pressure  upon  heart  and  lung. 
Whenever  fine  moist  rales  can  be  heard  over  the  sound  side, 
the  patient  is  in  some  danger  of  heart  failure  with  asphyxial 
oedema  of  the  only  working  lung.  Nor  is  the  risk  entirely 
to  be  ignored  even  in  small  effusions,  for  cases  of  this  nature 
have  been  met  with  in  which  fatal  syncope  has  occurred." 

We  have  seen  some  instances  in  which  great  agitation  and 
dyspnoea,  with  threatened  heart  failure,  have  occurred  in  the 
early  stages  of  rapid  effusion,  before  any  considerable  amount, 
of  fluid  has  collected.  Relief,  however,  has  in  these  cases  fol- 
lowed appropriate  treatment  by  opium. 

But  the  prognosis  in  a  case  of  sero-fibrinous  effusion  deals 
with  more  than  the  immediate  issue,  since  it  includes  the  ques- 
tion as  to  the  patient  subsequently  developing  pulmonary 
tuberculosis.  From  what  we  have  already  said  concerning 
the  frequent  association  of  tubercle  with  pleuritic  effusion, 
this  danger  is  a  real  one,  which  must  not  be  forgotten. 

Treatment. — The  treatment  of  acute  sero-fibrinous  pleurisy 
of  ordinary  severity  does  not  call  for  any  very  energetic 
measures.  In  the  first  stage  of  the  disease  our  object  is  to 
reduce  arterial  pressure  within  the  vessels  of  the  diseased 
pleura — vessels  which  are  temporarily  paretic  and  in  a  state 


SERO-FIBRINOUS   AND    HEMORRHAGIC   PLEURISY         107 

of  acute  turg'escence.  One  or  two  doses  of  aperient,  together 
with  saline  diaphoretics  and  diuretics,  are  useful  general 
measures  to  this  end.  At  the  first  onset  of  the  disease  small 
doses  of  aconite  may  sometimes  be  given  with  advantage  to 
reduce  arterial  pressure,  but  with  the  commencement  of  effu- 
sion this  remedy  should  be  stopped.  Rest  in  bed  must  be 
absolutely  enjoined,  even  in  the  least  severe  cases,  and  the 
diet  restricted  to  nutritious  fluids.  There  is  no  object  to  be 
gained  by  restraining  the  patient  from  taking  bland  drinks 
to  ease  thirst. 

To  lessen  the  intensity  of  the  local  lesion  as  judged  of  by 
pain  and  fever,  the  application  of  leeches  to  the  side  is  often 
of  great  value.  Hot  poultices  frequently  changed  are  also 
beneficial,  or  the  use  of  antiphlogistine,  servings,  by  the  dilata- 
tion of  superficial  capillaries,  to  ease  pressure  within  the 
deeper  branches  of  the  intercostal  vessels.  A  blister  may 
sometimes  be  applied  under  the  poultice,  especially  in  those 
cases  in  which  there  is  great  pain.  A  fair  amount  of  sleep 
must  be  secured  by  the  judicious  administration  of  opiates, 
which  may  be  given  in  the  form  of  Dover's  powder,  or  in 
adults,  if  the  pain  be  very  severe,  by  subcutaneous  injections 
of  morphia.  When  there  is  great  and  alarming  cardiac  agita- 
tion in  the  early  stages  of  the  effusion,  opium  is  distinctly 
indicated,  and  may  be  usefully  prescribed  with  camphor,  musk, 
or  other  diffusible  stimulant. 

The  temperature  of  the  patient  and  the  signs  of  effusion 
must  be  carefully  watched,  although  the  former  of  itself 
never  requires  treatment. 

Stage  of  Effusion. — Whilst  the  inflammatory  fever  is  at  its 
height  the  less  we  meddle  with  any  effusion  present — unless 
it  become  of  itself  a  danger— the  better.  We  must  bear  in 
mind  that  a  certain  amount  of  effusion  is  as  much  to  be  looked 
for  in  acute  pleurisy  as  exudation  into  the  air-vesicles  in 
pneumonia,  or  "running  at  the  nose"  in  nasal  catarrh;  and 
the  products  in  the  three  cases  do  not,  cceteris  paribus,  essen- 
tially differ.  The  pulmonary  exudation  consolidates  in  situ; 
the  nasal  product  stiffens  the  handkerchief;  and  the  exudation 
into  the  closed  pleural  sac,  though  remaining  fluid,  deposits  a 
certain  variable  amount  of  coagulum,  a  thin  layer  of  which 
covers  and  protects  the  roughened  surface  of  the  pleura, 
flakes  of  it  also  sometimes  floating  in  the  fluid.     In  other 


I08  DISEASES   OF   THE  LUNGS   AND   PLEURA 

cases  irregular  partitions  of  lymph  form  which  span  the 
pleural  cavity,  uniting  the  two  sides  and  dividing  the  fluid 
into  separate  compartments  (see  Plate  III.)-  Again,  given 
acute  inflammation  of  the  coverings  of  the  lungs,  a  certain 
amount  of  effusion  is  useful  in  separating  and  bathing  in  a 
bland  fluid  the  inflamed  and  tender  surfaces,  and  further,  in 
keeping  at  rest  the  affected  portion  of  lung.  It  is  too  often 
forgotten  that  the  lung  is  in  health  exercising  a  constant 
traction  upon  the  pleural  sac,  the  vessels  of  which  have  there- 
fore to  sustain  a  negative  pressure;  this  being  so,  it  is  but 
natural  and  physiological  that  if  these  vessels  become  tem- 
porarily weakened  and  congested  by  the  inflammatory  pro- 
cess, increased  exudation  should  proceed  from  them.  The 
effect  of  this  exudation  is  to  neutraHse  lung  traction,  and 
therefore  to  lessen  afflux  of  blood  to  the  weakened  vessels. 
It  is,  moreover,  the  surest  and  most  natural  way  of  giving 
that  rest  to  the  inflamed  surfaces  which  their  recovery 
requires. 

Fluid  effusion  being  thus  both  natural  and  salutary  in  acute 
pleurisy,  we  must  be  watchful,  but  not  meddlesome,  in  our 
treatment  of  its  earlier  stages.  Up  to  the  end  of  a  week  or 
ten  days  we  need  not,  in  ordinary  cases,  consider  how  to  pro- 
mote its  removal;  and,  in  the  majority  of  cases,  after  this 
period  the  fluid  will  gradually  subside  by  spontaneous  absorp- 
tion. At  this  stage  counter-irritation  is  of  undoubted  value, 
and  small  doses  of  iodide  of  potassium  may  be  added  to  the 
prescription.  As  the  absorption  is  being  effected,  pain  some- 
times arises  from  the  pleural  surfaces  again  coming  together. 
If  severe,  the  temporary  application  of  a  broad  band  of  adhe- 
sive plaster  round  the  affected  side  will  give  relief.  Mineral 
acid  tonics,  usually  with  iron,  are  now  required,  and,  after 
complete  subsidence  of  the  temperature,  change  of  air  will 
hasten  the  reabsorption  of  fluid  and  the  restoration  of  the 
function  of  the  lung.  For  some  years  to  come,  however,  the 
patient  must  remember  that  if  he  would  avoid  the  danger  of 
developing  pulmonary  tuberculosis  he  must  be  content  to 
take  matters  easily,  to  enjoy  long  holidays,  and  to  maintain 
his  vitality  at  the  highest  pitch  by  means  of  a  generous  dietary 
and  open-air  methods  of  life.  To  spend  the  first  winter  at  a 
high  Alpine  station  is  often  a  wise  proceeding.  If  he  be  con- 
tent to  follow  out  treatment  on  these  lines  the  outlook  is  good 


PLATE  III 


SERO-FIBRINOUS   AND   HEMORRHAGIC   PLEURISY         lOQ 

Paracentesis  Thoracis. — Towards  the  end  of  the  second  or 
third  week  of  ilhiess,  if  absorption  be  not  in  fair  progress, 
the  question  arises  whether  it  be  advisable  to  interfere  and 
remove  a  portion  of  the  fluid  by  paracentesis.  Thanks  to  the 
labours  of  Trousseau,  Hamilton  Roe""  (formerly  Physician  to 
the  Brompton  Hospital),  Bowditch,  Dieulafoy,  and  others, 
this  operation  has  been  rendered  safe  and  easy  of  perform- 
ance. The  following  propositions  in  regard  to  the  operation 
appear  to  us  justified  by  experience : 

1.  With  good  skodaic  resonance  down  to  the  third  rib,  and 
with  no  material  enlargement  of  the  side,  we  may  assume,  as 
we  have  already  pointed  out,  that,  although  much  fluid  be 
present,  the  lung  is  only  held  in  the  position  of  physiological 
rest.  At  an  early  stage  of  the  illness,  therefore,  operative 
interference  is  not  necessarily  called  for;  and  if  pyrexia  be 
still  present  under  these  circumstances  at  the  end  of  the 
second  week,  it  will  be  well  to  wait  a  little  longer  before 
performing  aspiration. 

2.  If  no  progress  in  absorption  has  been  made  by  the  end 
of  the  third  week,  a  portion  of  the  fluid  should,  as  a  rule,  be 
removed. 

3.  In  cases  in  which  the  effusion  mounts  up  to  the  second 
rib  or  higher,  extinguishing  skodaic  resonance,  and  causing 
decidedly  increased  measurement  of  the  side,  we  may  be  sure 
that  there  is   positive   intrathoracic   pressure,   impeding  the 
heart's  action,  and  compressing  the  lung  so  as  to  retard  the 
circulation   through   it.     In    such   a   case    the    pressure    may 
amount  to  i  or  i|  inches  of  mercury.     Under  these  circum- 
stances the  patient  is  in  danger  of  syncope.     The  signs  espe- 
cially indicative  of  danger — viz.,  Uvidity,  palpitation,  a  strain- 
ing   retching"    cough,    with    frothy    viscid    sputa,    sometimes 
streaked  with  a  speck  or  two  of  blood,  and  the  presence  on 
the  healthy   side   of  rather  fine   crepitant   rales — have   been 
already  pointed  out.     On  the  appearance  of  such  signs,  no 
matter  what  the  stage  of  the  disease,  immediate  interference 
is  called  for.     The  removal  of  two  or  three  pints  of  fluid  by 
the  aspirator  or  syphon  will  give  the  patient  immediate  relief, 
and  no    further    operation   may   be   necessary.     It   was    well 
pointed  out  by  the  late  Lord  Ilkeston"^  that  the  special  symp- 
toms of  danger  may  sometimes  be  in  abeyance  whilst  the 
patient  is  perfectly  quiet. 


no  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

4.  In  cases  in  which  the  effusion  has  occurred  on  the  side 
on  which  there  is  ah'eady  existing  lung-  disease  of  an  advanced 
tuberculous  nature,  we  should  be  loath  to  interfere,  as  experi- 
ence certainly  shows  that  an  effusion  checks,  and  tends  to 
arrest,  the  farther  spread  of  the  tuberculous  process. 

5.  In  cases  in  which  there  is  any  reason  to  suspect  that  the 
fluid  may  be  purulent,  quite  apart  from  any  question  as  to  its 
amount,  exploratory  puncture  must  be  at  once  resorted  to. 

Choice  of  Spot  for  Puncture. — Supposing  paracentesis  to 
be  necessary,  the  first  step  is  to  select  the  best  position  for 
puncture.  The  physician  is  responsible  in  choosing  the  site 
for  puncture,  and  must  not  share  the  responsibility  with 
others.  In  choosing  the  spot  he  has  to  be  sure  that  it  is  put 
of  reach  of  diaphragm  and  heart,  and  that  no  lung  is  there 
adherent.  The  sixth  space  in  the  mid-axillary  line,  as  a  rule, 
best  satisfies  these  conditions,  and  should  be  selected  if,  when 
tested  by  percussion,  palpation,  and  auscultation,  it  prove  satis- 
factory. This  spot  is  most  convenient  for  the  following  rea- 
sons :  (i)  it  is  most  accessible  whilst  the  patient  is  reclining 
in  an  easy  posture ;  (2)  the  parietes  are  here  moderately  thin, 
and  the  intercostal  space  sufficiently  roomy;  (3)  the  mamma 
in  the  female  is  out  of  the  way;  and  (4)  it  is  sufficiently  high 
up  to  be  free  from  danger  of  perforating  the  diaphragm. 
(5)  This  point  has  also  the  advantage  over  that  very  commonly 
chosen,  below  the  angle  of  the  scapula,  that  the  cannula  is 
less  likely  to  become  blocked  by  flocculi,  which  tend,  from  the 
position  of  the  patient,  to  gravitate  towards  the  back  of  the 
chest.  Most  of  the  dry  tappings  which  we  have  observed 
have  occurred  with  the  posterior  puncture.  (6)  Lastly,  this 
point  is  to  be  preferred  to  one  chosen  more  anteriorly,  as 
being  more  central  with  regard  to  the  effusion. 

In  special  cases  of  limited  effusion  the  point  for  puncture 
must  be  decided  upon  accordingly,  but  it  must  be  remembered 
that  a  central  rather  than  the  lowest  point  of  the  effusion 
should  be  selected. 

Method  of  Performing  Paracentesis. — The  fluid  may  be 
removed  from  the  chest  either  by  simple  syphonage  or  by 
means  of  an  aspirator.  If  the  syphon  be  employed,  a  simple 
trocar  and  cannula  should  be  used,  the  lateral  limb  of  the 
cannula  being  connected  with  a  suitable  receiver  by  means  of 
a  piece  of  elastic  tubing  two  or  three  feet  long,  filled  with 


SERO-FIBRINOUS    AND   HEMORRHAGIC   PLEURISY         I  I  I 

water  previously  boiled.  In  this  way  air  is  prevented  from 
entering"  the  chest  during  the  respiratory  movements.  The 
elastic  tube  should  be  intercepted  near  the  cannula  by  a  piece 
of  glass  tubing,  so  that  the  nature  of  the  fluid  may  be 
observed. 

Before  performing  paracentesis,  the  greatest  care  must  be 
taken  to  render  both  instruments  and  skin  aseptic;  otherwise 
organisms  may  be  introduced  and  acute  septic  suppuration  of 
the  pleura  be  set  up.  The  skin  around  the  site  for  puncture 
should  be  carefully  washed,  and  when  dry  painted  with  tincture 
of  iodine  or  sponged  over  with  some  antiseptic  solution.  The 
trocar  and  cannula  must  be  boiled. 

Everything  being  prepared,  and  the  patient  reclining  near  the 
edge  of  the  bed,  with  head  and  shoulders  slightly  raised,  and 
leaning  towards  the  affected  side,  a  small  area  of  skin  at  the 
spot  chosen  for  paracentesis  may  be  frozen  with  the  ethyl 
chloride  spray,  to  deaden  sensibility.  The  first  finger  of  the 
left  hand  should  then  be  pressed  into  the  intercostal  space 
and  the  trocar  inserted  immediately  over  the  upper  border  of 
the  rib  below,  so  as  to  avoid  the  intercostal  vessels  and  nerves 
which  lie  under  cover  of  the  rib  immediately  above.  By  a 
sharp  thrust  it  is  then  made  to  enter  the  pleural  cavity.  We 
may  add  that  we  have  frequently  performed  the  operation 
without  employing  any  anodyne.  In  no  case  is  a  general 
anaesthetic  necessary. 

When  the  fluid  has  been  struck,  it  may  be  allowed  to  run 
quietly  until  the  flow  ceases.  The  withdrawal  by  syphon  is 
always  gradual,  and  it  is  rarely  necessary  to  stop  the  opera- 
tion on  account  of  cough  or  other  trouble.  The  method  is 
useful  in  cases  in  which  the  more  convenient  aspirator  is  not 
at  hand. 

If  aspiration  be  employed,  the  form  of  instrument  most  con- 
venient is  that  invented  by  Potain  (Fig".  21),  and  it  answers 
admirably.  cork  (c,  Fig.  22),  made  of  india-rubber,  and  of 
such  dimensions  as  to  fit  accurately  any  ordinary  wine  or 
mineral  water  bottle,  is  perforated  by  two  tubes,  one  of  which 
a'  is  connected  with  the  exit  limb  of  the  cannula.  The  second 
tube  b'  is  adapted  to  an  exhausting  syringe.  Each  of  these 
tubes  is  supplied  with  a  stopcock,  and  the  tube  a'  in  connec- 
tion with  the  cannula  should  extend  somewhat  farther  into 
the  bottle  than  b'. 


112 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


Having  fitted  the  apparatus,  aspiration  is  sometimes  per- 
formed as  follows :  the  air  in  the  bottle  is  exhausted,  and 
then,  the  cannula  tubing  having  been  connected,  the  stop- 
cock a  is  opened,  when  the  bottle  rapidly  fills  with  fluid.  The 
stopcock  a  is  then  again  closed,  the  bottle  detached  and 
emptied,  and  the  process  repeated.  By  adopting  this  method 
of  practice,  however,  we  are  employing  quite  an  unknown 
suction  power,  which  may  amount  to  anything  short  of  15 
pounds  to  the  square  inch,  and  which  is  not  only  quite  un- 
necessary, but,  if  incautiously  used,  extremely  dangerous,  and 
especially  so  towards  the  latter  part  of  the  operation,  when 
there  is  already  negative  pressure  within  the  pleura.* 


Fig.  21. — Potain's  Aspiratoe. 

^  A  much  more  safe  and  useful  method  of  employing  aspira- 
tion is,  not  to  exhaust  the  bottle,  but  to  open  the  stopcock  a, 
and  to  keep  the  syringe  in  just  sufficient  action  to  permit  or 
encourage  the  flow  of  fluid  through  the  exit  tube  a'  into  the 
bottle.  When  the  bottle  is  filled,  the  stopcock  a  must  be 
closed  before  the  cork  is  withdrawn,  otherwise  there  will  be 
a  rush  of  air  into  the  chest. 

Both  the  methods  which  we  have  described  are  very  con- 

*  It  would  be  very  easy,  of  course,  by  a  pressure  gauge  fitted  into  the 
bottle,  to  know  at  any  moment  what  degree  of  aspiration  is  being  used 
but    this    arrangement    would   require   a    special    bottle,    whereas    a    great 
advantage  of   Potain's  cork   adjustment   is   that   it   renders   any   ordinary 
bottle  available.  ^ 


SERO-FIBRINOUS   AND  HEMORRHAGIC  PLEURISY        I13 

venient  and  safe  for  removing  fluid  from  the  chest,  the  syphon 
excelHng  the  aspirator  in  the  uniformity  and  measurability  of 
the  power  employed,  and  also  in  simplicity  and  freedom  from 
extra  fittings.  If  a  soft  plug  of  fibrin  block  the  cannula,  it 
may  be  impelled  through  the  tube  by  a  momentarily  increased 
aspiration  power,  or  it  may  be  dislodged  by  cautiously  thrust- 
ing back  the  trocar. 

The  cannula  used  should  have  near  the  end  a  lateral  as  well 
as  a  terminal  opening,  the  chance  of  its  becoming  blocked  by  a 
plug  of  lymph  being  thus  lessened. 

After  a  certain  portion  of  fluid  has  been  removed,  varying 
from  one  to  three  or  four  pints,  the  patient  begins  to  com- 


FiG.  22. — Showing  Certain  Details  of  a  Potain's  Aspirator. 


plain  of  oppression  in  the  chest,  and  often  experiences  a  pain 
below  the  cartilages,  probably  due  to  cramp  in  the  diaphragm. 
This  discomfort  can  be  relieved  by  moderately  firm  pressure 
with  the  hand  below  the  costal  margin,  but,  together  with  a 
troublesome  spasmodic  cough  which  comes  on  about  the 
same  time,  it  indicates  the  presence  of  negative  pressure 
within  the  thorax,  and  the  necessity  of  caution  in  continuing 
the  operation,  which,  if  the  symptoms  persist,  should  be 
stopped.  Indeed,  it  is  quite  unnecessary,  even  were  it  wise, 
to  contemplate  the  removal  of  all  the  fluid,  the  withdrawal  of 
a  small  portion  leading  often  to  a  rapid  absorption  of  the 
remainder,  perhaps  through  lessening  of  pressure  and  open- 
ing up   of  the   lymphatic   vessels.      If   the   warning   be   not 


il4  DISEASES   OF  THE  LUNGS   AND  fLEUR^ 

attended  to,  the  patient  is  liable  to  develope  that  condition 
recognised  as  albuminous  or  serous  expectoration,-'  in  which, 
with  straining-  cough,  he  brings  up  large  quantities  of  strongly 
aerated  sputum,  resembling"  water  whipped  up  with  white  of 
t%g.  The  fluid  contains  albumin,  and  is,  in  fact,  the  product 
of  acute  oedema  of  the  lungs.  The  condition  is  one  of  con- 
siderable danger,  and  will  be  dealt  with  more  fully  in  a  later 
chapter  (see  p.  354). 

Chronic  Sero-Fibrinous  EfiFusion. 

In  the  majority  of  cases  of  acute  sero-fibrinous  pleurisy 
recovery  is  effected  by  medicinal  and  local  treatment,  per- 
haps after  paracentesis  has  been  performed  on  one  or  two 
occasions.  But  patients  are  sometimes  met  with  in  whom, 
however  often  the  fluid  is  removed,  it  invariably  returns,  and 
in  whom  the  disease  may  therefore  be  termed  "chronic."  In 
certain  other  cases  the  initial  symptoms  are  extremely  slight, 
and  the  disease  may  be  described  as  chronic  from  the  first. 
In  both  classes  the  fluid  remains  serous,  although  occasionally, 
as  in  two  cases  which  we  have  seen,  a  heavy  deposit  of 
cholestcrin  crystals  may  occur,  sufficient  to  give  the  fluid  a 
silvery  or  golden-spangled  appearance,  the  colour  varying 
according  to  the  greater  or  less  amount  of  blood  present.^^ 
These  chronic  cases  have  become  distinctly  rare  now  that 
effusions  are  more  efficiently  treated  in  their  earher  stages. 
Such  patients,  even  with  very  large  effusions  into  the  pleura, 
may  live  for  long  with  surprisingly  little  discomfort.  Thus, 
some  years  ago,  we  had  under  occasional  observation  a  police- 
man, stalwart-looking  enough  to  frighten  thieves,  but  who 
for  four  or  five  years  had  his  left  pleura  full  of  fluid.  In  this 
instance,  after  a  few  partial  tappings,  it  became  evident  that 
no  expansion  of  the  lung  could  be  looked  for,  and,  in  the 
absence  of  any  urgent  symptoms,  it  was  not  thought  prudent 
to  submit  him  to  any  radical  measure  of  treatment  involving 
long  illness,  and  probably  a  permanent  thoracic  fistula. 

More  recently,  attempts,  sometimes  successful,  have  been 
made  to  deal  with  cases  of  this  kind  by  aspiration,  accom- 
panied by  the  introduction  of  measured  quantities  of  oxygen 
by  means  of  the  apparatus  employed  in  performing  artificial 
pneumothorax.  In  this  way,  as  Mr.  Morriston  Davies^*  has 
shown,  a  larger  quantity  of  fluid  can  be  withdrawn,  and  a  duly 


SERO-FIBHINOUS  AND  HEMORRHAGIC  PLEURISY        1 15 

registered  negative  pressure  left  within  the  pleura.  As  the 
oxygen  becomes  gradually  absorbed  a  continual  traction  is 
made  upon  the  collapsed  lung,  aiding  its  expansion,  which  in 
successful  cases  we  have  known  to  be  complete.  At  the  con- 
clusion of  the  operation  a  drachm  of  sterile  adrenalin  chloride 
solution,  I  in  1,000,  diluted  in  two  or  three  times  its  bulk  of 
normal  saline  solution,  may  also  be  injected  into  the  pleural 
cavity  with  a  view  to  diminish  the  secretion  of  fluid,  as  recom- 
mended by  Sir  James  Barr."  It  is  needless  to  add  that  during 
these  various  manipulations  the  strictest  antiseptic  pre- 
cautions must  be  observed. 

Hsemorrhagic  Plei»?isy. 

As  we  have  already  seen,  in  all  sero-fibrinous  pleurisies,  the 
fluid  exuded  into  the  pleural  cavity  contains  a  Hmited  number 
of  red  blood-corpuscles.  These  do  not,  as  a  rule,  exceed 
200  to  300  per  cubic  millimetre,  and  are  insufficient,  therefore, 
even  to  tinge  the  fluid.  Sometimes,  however,  their  number 
becomes  so  considerable  that  the  liquid  acquires  a  blood- 
stained and  haemorrhagic  character,  and  may  even  contain 
500,000  or  more  red  corpuscles  to  the  cubic  millimetre.  The 
colour  of  the  liquid  varies  somewhat  in  different  cases.  It  is 
bright  red,  if  the  blood  has  been  recently  effused;  in  cases  of 
older  date  the  tint  may  be  red-brown,  or  even  brown. 

Trousseau"*  believed  that  malignant  disease  affecting  the 
serous  membrane  was  the  common  cause  of  such  haemor- 
rhagic pleurisy,  and  the  influence  of  his  teaching  has  extended 
to  the  present  day.  Nevertheless,  the  statement  is  only  par- 
tially true,  for,  apart  from  injury  involving  the  fracture  of  a 
rib,  it  would  be  more  correct  to  say  that  there  are  two  causes, 
tubercle  and  cancer,  either  of  which  may  be  responsible  for 
the  condition.  We  must  further  remember  that,  although 
both  cancer  and  tubercle  are  accountable  for  most  of  the 
haemorrhagic  pleurises  which  occur,  yet  neither  of  them  is 
by  any  means  essentially  accompanied  by  an  effusion  of  this 
nature. 

The  escape  of  the  red  corpuscles  into  the  fluid  may  be  due 
in  some  cases  to  the  rupture  of  minute  bloodvessels  in  recent 
adhesions,  and  in  others  to  a  toxic  alteration  in  the  vessel 
walls,  whereby  their  permeability  is  increased.     In  tlie  malig- 


Il6  DISEASES  OP  THE  LUNGS  AND  PLEURA 

nant  forms  of  the  specific  fevers  and  in  certain  blood  diseases, 
such  as  scurvy,  purpura  and  haemophiHa,  the  exudation  may 
be  thus  blood-stained. 

Clinically,  hsemorrhagic  pleural  effusion  does  not  present 
any  special  symptoms  whereby  it  may  be  distinguished  from 
other  varieties  of  the  disease,  and  it  is,  as  a  matter  of  fact, 
only  recognised  by  exploratory  puncture.  The  prognosis  in 
each  case  will  vary  with  the  cause,  and  is  not  made  more 
grave  by  the  blood-stained  nature  of  the  fluid. 

Hjemothorax,  or  the  extravasation  of  pure  blood  into  the 
pleural  cavity,  will  be  discussed  in  a  later  chapter  (see  p.  157). 


REFERENCES. 

1  "  The  ^Etiology,  Immediate  and  Remote  Prognosis  of  Primary  Pleurisy 
with  Serous  Effusion,"  by  C.  E.  Hedges,  M.D.,  St.  Bartholomew's  Hosfiial 
Reports,  1900,  vol.  xxxvi.,  p.  75. 

^  "  Remarks  on  the  Tuberculous  Nature  of  the  So-called  Simple  Pleuritic 
Eittusion,"  by  Alfred  G.  Barrs,  M.D.,  British  Medical  Journal,  1890,  vol.  i., 
p.  1058. 

^   British  Medical  Journal,  1912,  vol.  i.,  epit.,  No.  64. 

*  "  Racherches  sur  les  Lesions  Anatomo-Pathologiques  et  la  Nature  de 
la  Pleuresie,"  par  MM.  A.  Kelsch  et  L.  Vaillard,  Archives  de  Physiologie 
Normale  et  Pathologique,  Paris,  1866,  vol.  ii.,  p.  162. 

*  (i)   "  Nouvelle  Methode  pour  Isoler  le  Bacille  de  Koch  des  Humeurs 

de    rOrganisme,"    par    M.    le    Dr.     Andre    Jousset,    La    Semaine 
Medicate,  1903,  p.  22. 
(2)  "  L'Inoscopie,"  par  Andre  Jousset,  Archives  de  Medecine  Exferi- 
mentale  et  d' Atiatovtie  Pathologique,  Paris,  1903,  tome  xv.,  p.  289. 

*  "  Recherches  Experimentales  sur  la  Nature  des  Pleuresies  Sero- 
fibrineuses,"  par  M.  le  Dr.  Netter,  Bulletins  et  Memoires  de  la  Societe 
Medicate  des  Hdfitaux  de  Paris,  1891,  p.  176. 

'  "  Les  Rapports  entre  la  Pleuresie  Sereuse  et  la  Tuberculose,"  par 
M.  Ei'chhorst  (de  Zurich),  La  Semaine  Medicate,  1895,  p.  206. 

8  Quoted  by  Dr.  John  H.  Musser,  Nothnagel's  Encyclofedia  of  Practical 
Medicine,  English  Edition,  article  on  "  Diseases  of  the  Pleura,"  p.  820. 
Philadelphia  and  London,  1903. 

'  "  Applications  Cliniques  de  I'Etude  Histologique  des  fipanchements 
Sero-Fibrineux  de  la  Plevre  (Pleuresies  Tuberculeuses),"  par  MM.  Widal 
et  Ravaut,  Comftes  Kendus  H ebdomadaires  des  Seances  et  Mimoires  de  la 
Societe  de  Biologie,  Paris,  1900,  p.  648. 

"  "  A  Study  of  Cytodiagnosis  :  with  Special  Reference  to  its  Application 
in  Clinical  Medicine,"  by  E.  Athole  Ross,  Transactions  of  the  Pathological 
Society  of  London,  1906,  vol.  Ivii.,  p.  361. 


SERO-FIBRINOUS    AND    H^iiMORRHAGIC    PLEURISY         II7 

"  "  Report  on  Pathological  Effusions,"  by  W.  D.  Halliburton,  M.D., 
British  Medical  Journal,  1890,  vol.  ii.,  p.  195. 

^*  A  Textbook  of  Chemical  Physiology  and  Pathology,  by  Professor 
W.  D.  Halliburton,  M.D.,  p.  346.     London,  1891. 

"  "  The  Curved  Line  of  Pleuritic  Effusion,"  by  Calvin  Ellis,  M.D., 
The  Boston  Medical  and  Surgical  Journal,  1876,  vol.  xcv.,  p.  689. 

1*  "  Notes  on  Displacement  of  the  Heart,"  by  R.  Douglas  Powell,  M.D., 
British  Medical  Journal,  1869,  vol.  ii.,.p.  54. 

**  See  also  A  Treatise  on  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Chest,  by  William  Stokes,  M.D.,  New  Sydenham  Society  edition,  pp.  485, 
512.     London,  1882. 

"  Pneumono-Dynamics,  by  G.  M.  Garland,  M.D.,  New  York,  1878. 

•'  "  The  Paravertebral  Triangle  of  Dulness  in  Pleural  Effusion  (Grocco's 
Sign),"  by  W.  S.  Thayer,  M.D.,  and  Marshal  Fabyan,  M.D.  (with  biblio- 
graphy), The  American  Journal  of  the  Medical  Sciences,  1907,  vol.  cxxxiii., 
P-  14- 

'*  Lectures  on  Clinical  Medicine,  by  A.  Trousseau,  New  Sydenham 
Society  edition,  vol.  iii.,  p.  198.     London,  1870. 

*•  For  a  most  complete  consideration  of  the  subject,  see  Diseases  of  the 
Lungs  and  Pleura,  by  the  late  Wilson  Fox,  M.D.,  F.R.S.,  Appendix  A, 
p.    1085,   "  Sudden  Death  in   Pleurisy."     London,   1891. 

20  "  Qn  Paracentesis  Thoracis  as  a  Curative  Measure  in  Empyema  and 
Inflammatory  Hydrothorax,"  by  Hamilton  Roe,  M.D.,  Senior  Physician 
to  the  Westminster  Hospital,  and  Physician  to  the  Hospital  for  Diseases 
of  the  Chest,  Transactions  of  the  Royal  Medical  and  Chirurgical  Society, 
1844,  vol.  xxvii.,  p.  198. 

'^  On  the  Treatment  of  Pleurisy  and  Pleuritic  Effusions,  by  Balthazar 
Foster,  M.D.,  F.R.C.P.,  the  Birmingham  Medical  Review,  1881,  vol.  x. 
(new  series,  vol.  iv.),  p.  239. 

"  See  "  Albuminous  Expectoration  following  Paracentesis  of  the  Chest " 
(with  bibliography),  by  P.  Horton-Smith  Hartley,  M.D.,  St.  Bartholomew's 
Hosfital  Reports,  1905,  vol.  xli.,  p.  77. 

*^  "  A  Note  on  a  Case  of  Pleuritic  Effusion  in  which  Cholesterine  formed 
an  Important  Constituent,  with  remarks  on  the  Derivation  of  Cholesterine 
in  Such  Cases,"  by  Thomas  Harris,  M.D.,  F.R.C.P.,  the  Medical 
Chronicle,  1906,  vol.  xlv.,  p.  141. 

^■*  [a)  "  A  Note  upon  the  Complete  Removal  of  Pleural  Effusions  by  the 
Regulation  of  Intrathoracic  Pressure  during  Aspiration  (Oxygen 
Replacement),"  by  H.  Morriston  Davies,  M.C.,  F.R.C.S.,  The 
Lancet,  1912,  vol.  ii.,  p.  1774.  See  also — 
{b)  "  Surgery  of  the  Lung  and  Pleura,"  by  H.  Morriston  Davies, 
M.A.,   M.D.,  M.C.,   F.R.C.S.,  p.  46.     London,   1919. 

25  "  On  the  Pleurae  :  Pleural  Effusion  and  its  Treatment,"  by  Sir  James 
Barr^  M.D.,  LL.D.,  being  the  Bradshaw  Lecture  for  1907,  British  Medical 
Journal,  1907,  vol.  ii.,  p.  1289.  ; 


CHAPTER  VIII 

SUPPURATIVE    PLEURISY 

Suppurative  pleurisy,  or,  to  use  it«  more  ancient  name,  Em- 
pyema, does  not  differ  essentially  in  clinical  outline  from  the 
sero-fibrinous  variety  considered  in  the  preceding  chapter. 
As  in  the  latter,  the  pleura  becomes  injected  and  inflamed,  and 
effusion  takes  place,  but,  owing  to  the  depressed  vitality  of 
the  subject,  the  character  and  virulence  of  the  micro- 
organisms concerned,  and  the  consequent  severity  of  the  pro- 
cess, pus,  not  serum,  is  effused.  The  pus  varies  much  in  con- 
sistency, being  thin  as  a  rule  in  streptococcic  cases,  thicker 
and  more  "laudable  "  in  those  produced  by  the  pneumococcus. 
Lymph  is  commonly  found  attached  to  the  pleural  surfaces, 
over  which  it  forms  a  thick  covering,  and  flecks  of  the  same 
are  seen  in  more  or  less  abundance  floating  in  the  fluid. 

.etiology. — In  considering  the  aetiology  of  suppurative 
pleurisy  we  are  struck  by  the  relation  which  it  bears  to  age, 
the  disease  being  much  more  common  in  childhood,  whereas 
the  chief  incidence  of  the  sero-fibrinous  variety  occurs  between 
the  ages  of  twenty  and  forty.  Both  varieties  are  more  com- 
mon in  males  than  in  females. 

Clinically,  we  find  empyema  associated  frequently  with  cer- 
tain morbid  states.  It  is  thus  very  apt  to  occur  in  connection 
with  pneumonia  or  gangrene  of  the  lung,  and  when  pleurisy 
occurs  in  such  diseases  as  pyaemia,  scarlet  fever,  typhoid 
fever  and  the  puerperal  state,  it  is  mostly  of  the  purulent 
variety.  Sometimes  it  is  secondary  to  disease  below  the  dia- 
phragm, such  as  liver  abscess  or  gastric  ulcer.  In  many 
cases,  however,  suppurative  pleurisy  is  not  a  sequel  to  any 
other  condition,  but  constitutes  in  itself  the  whole  disease. 
In  these  cases  the  sanitary  surroundings  of  the  patient  should 
be  carefully  investigated,  as  in  many  instances  it  will  be  found 
that  defective  drainage  is  really  at  the  root  of  the  «iatter. 

ii8 


SUPPURATIVK  PLEURISY  II9 

The  micro-organisms  which  are  chiefly  responsible  for  sup- 
puration in  the  pleura  are  the  pneumococcus  and  the  strepto- 
coccus. In  an  examination  of  137  cases  in  the  hospitals  of 
Boston  and  New  York,  Dr.  Lord'  found  the  pneumococcus 
present  in  54  (39'4  per  cent.);  the  streptococcus  in  28  (20'4 
per  cent.);  and  the  staphylococcus  in  5  (3-6  per  cent.).  In  22 
(16  per  cent.)  a  mixed  microbial  flora  was  obtained,  and  in  25 
(i8*2  per  cent.)  the  cultures  were  sterile,  indicating  possibly 
the  presence  of  the  tubercle  bacillus,  or  more  probably  a 
pneumococcic  infection  in  which  the  organism  had  already 
perished. 

The  original  statistics  of  Netter,-  to  whom  we  are  indebted 
for  so  much  of  our  early  knowledge  of  the  bacteriology  of 
pleurisy,  pointed,  in  Paris  at  least,  to  the  more  frequent  pres- 
ence of  the  streptococcus  in  empyemata  occurring  in  the 
adult.  But  this  is  not  the  case  in  England,  and  at  St.  Bar- 
tholomew's Hospital,  in  32  consecutive  examinations,  the  pneu- 
mococcus was  found  in  75  per  cent.,  and  the  streptococcus 
in  only  20  per  cent,  of  the  cases.  Among  children,  Dr.  Clive 
Riviere  informs  us  that  in  63  examinations  at  the  East  Lon- 
don Hospital  for  Children,  he  found  the  pneumococcus  in 
pure  culture  in  55  cases  (87-3  per  cent.),  once  also  in  conjunc- 
tion with  the  streptococcus,  and  once  with  the  staphylococcus 
aureus.  During  the  recent  epidemic  of  influenza,  however, 
the  bacteriology  has  been  exceptional,  and  the  streptococcus 
has  proved  in  the  adult  to  be  the  predominant  organism. 

Occasionally  such  organisms  as  the  influenza,  diphtheria 
and  typhoid  bacilli,  the  bacillus  coli,  and  members  of  the 
streptothrix  group,  are  to  be  met  with  in  the  pus. 

Symptoms. — Those  of  suppurative  pleurisy  do  not  differ 
strikingly  from  those  of  serous  effusion,  and  in  many  cases 
it  is  impossible  to  make  a  certain  diagnosis  from  symptoms 
and  signs  alone.  The  symptoms  are  as  a  rule  less  acute,  but 
more  adynamic  in  character  than  in  sero-fibrinous  pleurisy. 
Rigors  or  slight  shiverings  are  of  more  frequent  occurrence, 
and  the  daily  oscillations  of  temperature  tend  to  be  more 
marked,  and  to  continue  week  after  week.  The  pulse  is  from 
the  first  more  frequent,  and  keeps  up  its  rapidity  throughout 
the  disease.  The  tongue  is  more  coated,  the  general  condi- 
tion of  the  patient  more  depressed  and  anxious,  and  emacia- 
tion proceeds  more  rapidly.     But  perhaps  the  most  important 


120  DISEASES    OF   THE   LUNGS   AND   PLEURA 

sign  of  the  effusion  being  purulent  (although  not  absolutely 
characteristic)  is  the  occurrence  of  hectic  sweats  whenever 
the  patient  falls  asleep.  Diarrhoea  is  a  frequent,  though  not 
an  exclusive,  concomitant  of  pus  in  the  pleura.  Occasionally, 
the  symptoms  of  empyema,  especially  in  old  people,  are  but 
slightly  marked,  and  sometimes  they  may  be  wholly  merged 
in  those  of  some  associated  disease  of  the  lung,  such  as  pneu- 
monia or  phthisis. 

Physical  Signs. — These  must  necessarily  be  for  the  most 
part  the  same,  whether  the  case  be  one  of  simple  or  suppura- 
tive pleurisy;  but  we  may  consider  whether  there  are  any 
physical  signs  which  are  characteristic  of  pus  in  the  pleura, 
and  by  means  of  which  it  is  possible  to  distinguish  a  purulent 
from  a  serous  effusion. 

Judging  from  our  own  experience,  we  may  say  that  evident 
pointing,  with  fluctuation,  is  the  only  certain  sign  of  the  effu- 
sion being  purulent.  GEdema  of  the  chest  wall  is  very  nearly 
pathognomonic,  but  has  occasionally  been  seen  in  cases  of 
sero-fibrinous  effusion.  But  these  are  late  signs,  which  with 
modern  methods  of  treatment  are  now  rarely  seen.  The 
course  of  the  temperature  is  of  itself  of  little  assistance.  It 
may  not  be  higher  than  m  serous  pleurisy,  and  in  rare  cases 
there  may  be  no  attendant  fever. 

It  was  maintained  some  few  years  ago  by  Professor 
Baccelli'  of  Rome  that  by  the  mode  of  transmission  of  the 
whispered  voice-sounds — pectoriloquie  aphonique — the  diag- 
niDsis  could  be  made  with  certainty.  In  order  to  appreciate 
this  sign,  the  unaided  ear  must  be  applied  to  some  convenient 
point  of  the  affected  side,  such  as  the  dull  region  posteriorly 
below  the  angle  of  the  scapula,  and  the  patient  directed  to 
whisper  some  rough  words,  such  as  "  trente  trois  "  or  "  one, 
two,  three."  These  will  be  well  conducted  to  the  ear  if  the 
fluid  be  serous ;  not  so  if  it  be  purulent.  Dr.  Baccelli's  theory 
to  account  for  the  difference  of  conduction  in  the  two  cases 
is  that  in  serous  effusions  the  fluid,  being  thin  and  homo- 
geneous, transmits  vibrations  with  facility;  but  the  more  the 
fluid  departs  from  the  homogeneous  nature  of  serum,  and  the 
greater  the  number  of  corpuscular  elements  which  it  contains, 
the  less  complete  is  the  conduction  of  sound  through  it! 
Experience,  however,  shows  that,  although  of  some  use^as  an 
additional  sign,  this  sign  does  not  possess  the  crucial  value 


SUPPURATIVE  PLEURISY  121 

attributed  to  it  by  its  distinguished  advocate.  Pectoriloquie 
aphonique  is  heard  in  perfection  in  some  cases  of  pure  sero- 
fibrinous effusion,  but  we  have  also  heard  it  very  well  marked 
in  certain  cases  of  purulent  pleurisy,  and  perfectly  in  cases  of 
foetid  sero-purulent  effusion.* 

It  has  been  suggested  again,  that  the  X-rays  may  be  used 
to  effect  the  diagnosis,  some  observers  holding  that  the 
shadow  cast  by  pus  is  denser  than  that  produced  by  serum, 
and  that  the  former  completely  obscures  the  ribs,  whilst  the 
latter  does  not.  Here  again,  however,  the  rule  is  not  abso- 
lute. In  several  cases  of  serous  effusion  (in  the  adult),  which 
we  have  examined,  we  have  found  the  outline  of  the  ribs 
obliterated,  and  other  observers  have  had  a  similar  experi- 
ence. In  both  forms  of  effusion  the  upper  limit  of  the  shadow 
when  viewed  upon  the  screen  is  often  somewhat  curved,  the 
outer  or  axillary  edge  attaining  the  highest  level. 

Of  more  value  in  a  doubtful  case  is  an  examination  of  the 
patient's  blood.  In  empyema  a  leucocytosis  is  generally 
present,  and  the  number  of  white  cells  may  reach  a  very  high 
figure.  In  sero-fibrinous  effusions  in  the  adult,  on  the  other 
hand,  unless  otherwise  complicated  the  leucocytes  are  usually 
normal  in  number  or  only  slightly  increased :  a  count  above 
15,000  is  indeed  altogether  exceptional,  and  if  observed  would 
point  to  empyema.  In  children,  however,  a  leucocytosis  is 
sometimes  present  even  in  sero-fibrinous  cases. 

From  what  we  have  said  it  will  appear  that  the  distinction 
between  a  purulent  and  a  serous  pleurisy  must  in  many  cases 
be  a  matter  of  considerable  difficulty.  The  exploring  syringe 
should  therefore  be  used  in  all  doubtful  cases  as  a  matter  of 
routine.  Too  fine  a  needle  must  not  be  employed,  or  the  pus, 
if  thick  and  viscid,  as  in  many  cases  of  pneumococcic  infection, 
may  not  be  withdrawn.  But  even  with  a  large  needle  it  some- 
times happens  that  a  shred  may  block  the  orifice  and  the  punc- 
ture be  apparently  without  result.  It  is  wise,  therefore,  in  all 
such  cases,  after  withdrawing  the  syringe,  carefully  to  examine 
any  material  contained  in  the  terminal  end  of  the  cannula.  In 
this  way  we  may  sometimes  prove  that  pus  has  really  been 
struck,  though  at  first  sight  nothing  may  have  been  withdrawn. 
Strict  antiseptic  precautions  must  in  all  cases  be  employed. 

Pulsation  of  the  Fluid. — There  is  one  other  physical  sign 
which,  though  not  invariably  restricted  to  purulent  cases,  is 


122  DISEASES   OF  THE  LUNGS   AND   PLEURA 

yet,  when  present,  far  more  often  met  with  in  this  variety  of 
effusion,  and  may  therefore  be  best  considered  here.  We 
refer  to  pulsation  communicated  to  the  fluid  by  the  heart's 
action,  and  in  some  cases  closely  simulating  that  of  aneurism. 
The  phenomenon  was  first  described  in  1844  by  MacDonnell, 
of  Dublin,  a  pupil  of  Graves  and  Stokes,  and  is  of  great 
rarity.  To  cases  exhibiting  it  the  name  empyema  piilsans 
has  been  applied.  The  sign  is  not  restricted  to  any  one 
variety  of  empyema,  but  is  observed  for  the  most  part  in  very 
chronic  left-sided  cases,  in  which  the  effusion  is  large.  The 
pulsation  may  manifest  itself  only  in  a  portion  of  the  empyema 
which  has  penetrated  the  chest  walls;  and  in  this  case  it  is 
more  definitely  expansile  in  character.  In  other  cases  the 
impulse  is  not  confined  to  any  definite  tumour,  but  may  be 
felt  over  a  limited  area  of  the  chest,  most  commonly  in  the 
antero-lateral  region  of  the  left  side. 

The  cause  of  the  phenomenon  is  not  very  clear.  In  some 
of  the  cases  pericarditis  with  effusion  has  been  present  in 
addition  to  the  empyema,  and  Traube  explained  the  condition 
as  being  due  in  part  to  suppurative  softening,  with  increased 
extensibility  of  the  costal  pleura,  and  in  part  to  the  presence 
of  pericardial  effusion  favouring  the  transmission  of  the 
heart's  impulse.  But  in  the  light  of  the  following  cases  such 
explanations  are  insufficient. 

Some  years  ago  the  late  Professor  Maclean  was  kind  enough  to  allow 
one  of  us  to  examine  at  Netley  a  soldier  who  had  a  very  excessive  effu- 
sion into  the  left  pleura,  and  who  had  so  marked  a  pulsation  in  the  left 
supramammary  region  as  to  cause  some  hesitation  in  performing  para- 
centesis, lest  there  should  be  a  large  aneurism  in  addition  to  the  hydro- 
thorax.  A  right  judgment  was,  however,  arrived  at,  and  a  large 
quantity  of  serous  fluid  having  been  removed,  the  doubtful  sign  of 
aneurism  disappeared.  There  was  no  evidence  of  pericarditis  in  this 
case. 

Another  case  of  effusion,  right-sided  and  of  older  standing,  came 
under  our  notice  at  the  Brompton  Hospital,  in  which  a  rhythmic 
impulse  conveyed  through  the  fluid  suggested  aneurism  as  a  complica- 
tion. The  fluid  was  removed  by  several  tappings,  and  the  symptoms 
of  aneurism  disappeared.  The  liquid  was  somewhat  opaque  and  at 
first  slightly  blood-stained. 

From  these  cases  it  is  clear  that  neither  suppuration  in  the 
sac  nor  pericarditis  is  essential  for  the  production  of  pulsa- 
tion, and  probably  nothing  more  is  needed  to  account  for  the 
phenomenon  than  an  amount  of  fluid,  of  whatever  kind,  which 


SUPPURATIVE  PLEURISY  123 

shall  exercise  a  certain  degree  of  pressure  (neither  too  much 
nor  too  little)  upon  the  heart. 

Another  very  rare  pressure  effect  which  we  have  observed 
in  two  or  three  instances  is  an  altered  quality  of  voice  and 
cough.  A  husky  voice  and  a  laryngeal  quality  of  cough, 
undistinguishable  from  that  so  often  heard  in  cases  of 
mediastinal  tumour  or  aneurism,  gave  Irise  in  these  cases  to 
great  doubt  as  to  the  diagnosis,  yet  both,  phenomena  dis- 
appeared after  paracentesis. 

Special  Varieties  of  Empyema. 

1.  Foetid  Empyema. — It  sonietimes  happens  that  when  fluid 
is  drawn  off  by  exploratory  puncture  from  tlT«  chest  it  is 
found  to  be  extremely  foetid  in  character.  This  is  due  to  the 
presence  of  micro-organisms,  which  produce  by  their  growth 
certain  evil-smelHng  substances.  In  some  cases  bacillus  coli 
has  been  found,  in  others  various  putrefactive  organisms, 
some  of  them  anaerobic  in  character.  No  one  organism  is 
therefore  responsible  for  the  condition. 

This  variety  of  empyema  may  be  primary,  and  is  then  not 
uncommonly  encysted,  or  it  may  follow  upon  some  disease, 
such  as  pulmonary  gangrene  or  bronchiectasis.  We  have 
seen  it  also  rapidly  bring  to  a  fatal  termination  a  case  of 
chronic  hydropneumothorax.  The  symptoms,  though  some- 
what more  severe,  do  not  differ  materially  from  those  of 
ordinary  empyemata.  Indeed,  the  nature  of  the  disease  is 
generally  revealed  by  the  exploring"  syringe. 

The  prognosis  must  depend  largely  upon  the  cause,  but, 
provided  there  be  no  serious  lung  disease  in  the  background, 
and  early  operation  be  resorted  to,  the  outlook  of  the  case  is 
not  more  grave  than  that  of  a  simple  case  of  empyema. 

2.  Tuberculous  Empyemata. — Suppurative  pleurisy  some- 
times attacks  a  patient  already  the  subject  of  phthisis,  and  is 
then  usually  due  to  one  or  other  of  the  pyogenic  organ- 
isms which  are  commonly  responsible  for  the  disease. 
Occasionally  it  happens  that  the  empyema  results  from  the 
action  of  the  tubercle  bacillus  alone,  and  such  cases  present 
certain  peculiarities.  Usually  they  are  of  an  exceedingly 
chronic  type,  the  presence  of  fluid  within  the  chest  being  dis- 
covered in  some  cases  almost  by  accident.  In  others  the 
disease  commences  as  a  sero-fibrinous  pleurisy,  and  after  one 


124  DISEASES   OF   THE   LUNGS   AND   PLEURA 

or  two  tappings  the  fluid  withdrawn,  at  first  clear,  becomes 
gradually  opalescent  and  then  sero-purulent,  even  in  the 
absence  of  other  organisms  than  the  tubercle  bacillus.  In 
either  case  the  symptoms  are  very  slight.  There^  may  be  no 
fever,  and  the  only  complaint  is  of  shght  dyspncea  on  exer- 
tion. The  fluid,  as  we  have  indicated,  is  commonly  rather 
sero-purulent  or  opalescent  than  truly  purulent. 

The  patient  may  live  for  years,  death  finally  ensuing  from 
the  supervention  of  tuberculous  disease  elsewhere,  or  through 
some  intercurrent  malady. 

Very  occasionally,  as  in  a  case  recorded  by  the  late  Sir 
William  Osier,"  suppurative  tuberculous  pleurisy  may  run  an 
acute  course. 

The  patient  was  a  woman,  twenty-one  years  of  age,  whose  illness  set 
in  abruptly  with  shivering  and  severe  pain  in  the  right  side,  and  was 
accompanied  by  high  and  irregular  fever  until  her  death  six  weeks  later. 
At  the  autopsy  the  right  pleura  was  found  thickened  and  infiltrated, 
and  to  contain  between  its  adherent  surfaces  numerous  small  pockets 
of  pus.  Tubercle  bacilH  were  extraordinarily  abundant  in  the  pus,  and 
cultures  proved  the  absence  of  other  micro-organisms.  In  addition  to 
the  pleurisy,  recent  miliary  tuberculosis  of  the  lungs,  spleen,  and 
kidneys  was  found. 

Such  cases  are  exceedingly  rare. 

3.  Localised  or  Encysted  Empyema. — We  have  spoken 
hitherto  of  the  signs  and  symptoms  of  suppurative  pleurisy 
affecting  the  general  pleural  cavity,  but  we  must  remember 
that  the  disease  may  be  limited  in  its  extent,  giving  rise  to 
special  symptoms,  according  as  it  is  interlobar,  mediastinal, 
or  diaphragmatic. 

(i)  In  the  interlobar  variety  the  pus  is  contained  within 
one  of  the  fissures  of  the  lung,  the  edges  of  the  fissure  being 
glued  together  as  the  result  of  the  inflammation.  The  symp- 
toms, such  as  cough,  fever,  dyspnoea,  will  suggest  disease  of 
the  respiratory  organs,  but  the  absence  of  definite  physical 
signs  will  render  the  diagnosis  uncertain,  until,  as  not  uncom- 
monly occurs,  rupture  into  a  bronchus  and  the  sudden  expec- 
toration of  pus  reveals  the  nature  of  the  disease.  In  such 
cases  the  X-rays  are  of  assistance,  reveahng  the  presence  of 
a  rounded  shadow  within  the  chest,  which,  from  the  circum- 
stances of  the  case,  is  strongly  suggestive  of  encysted  fluid. 

(2)  The  inflammation  is  sometimes  limited  to  the  pleura 
covering  the  mediastinal  surface  of  the  lung.  Such  mediastinal 


SUPPURATiVE  PLEURISY  1 25 

pleurisy  may  affect  the  re;gion  of  the  anterior  mediastinum, 
when  the  signs  often  suggest  a  large  pericardial  effusion. 
More  commonly  the  posterior  mediastinum  is  attacked,  when 
symptoms  of  pressure  upon  the  cesophagus  and  trachea, 
developing  rapidly  and  brought  to  an  abrupt  close  by  the 
sudden  expectoration  of  pus,  are  the  chief  signs. 

(3)  Diaphragmatic  Pleurisy. — This  variety  we  have  already 
discussed  in  dealing  with  simple  pleurisy  (see  p.  88). 

Course  and  Termination  of  Untreated  Empyemata. — A  few 
cases  are  on  record  which  show  that  occasionally  an  empyema 
may  undergo  spontaneous  absorption  and  the  patient  com- 
pletely recover.  The  examples  have  been  mostly  cases  of 
pneumococcic  pleurisy  in  children.  Such  a  fortunate  termina- 
tion is,  however,  exceedingly  rare,  and  must  not  be  expected. 

If  left  untreated,  an  empyema  may  prove  fatal  in  a  short 
time  from  septicaemia  or  other  septic  complications,  such  as 
pericarditis,  or,  more  rarely,  cerebral  abscess.  In  other  cases 
it  will  rupture  through  the  lung,  with  perhaps  immediately 
fatal  results  from  flooding  of  the  brojichial  tubes,  or  dis- 
charge in  an  intermitting  manner  and,  in  a  certain  proportion 
of  instances,  terminate  in  recovery.  On  the  other  hand,  the 
pus  may  burrow  through  the  chest  wall,  and  point  externally. 
This  usually  occurs  in  more  chronic  cases,  which  are  now 
happily  but  rarely  seen,  although,  before  early  operation  was 
resorted  to,  they  were  common.  The  empyema  points  per- 
haps most  often  inThe  fifth  space  anteriorly,  in  the  nipple 
line,  but  may  do  so  in  other  situations,  both  in  the  front  and 
back  of  the  chest.  After  a  short  time  the  skin  gives  way  and 
the  pus  is  evacuated,  but  the  drainage  is  rarely  satisfactory 
and  suppuration  continues.  The  patient  as  a  rule  succumbs 
to  lardaceous  disease,  recovery  in  these  untreated  cases  being 
rare. 

Cases  have  occurred  in  which  an  empyema  has  burst  into 
the  pericardium,  peritoneal  cavity,  or  the  cesophagus.  In 
other  instances  the  pus  has  entered  the  sheath  of  the  psoas 
muscle  and  formed  a  psoas  abscess,  or,  as  Mr.  Stephen  Paget'* 
and  others  have  recorded,  has  pointed  in  the  lumbar  or  gluteal 
region.  In  other  cases  again  a  perinephritic  abscess  has 
been  simulated.  To  this  variety  of  the  disease  the  term 
migrating  or  wandering  empyema  has  been  applied. 

Diagnosis. — In  a  case  presenting  the  cardinal  signs — dul- 


126  DISEASES  OF  THE  LUNGS  AND  PLEURA 

ness,  absence  of  vocal  fremitus,  and  displaced  heart— with 
other  subsidiary  signs  indicative  of  fluid  in  the  pleura,  and 
presenting  symptoms  suggestive  of  the  effusion  being  puru- 
lent, the  use  of  the  exploring  syringe  forms  the  crucial  test. 
It  is  not  a  little  surprising,  however,  in  actual  practice  to  find 
how  difficult  it  is  sometimes  to  strike  the  pus-containing  cavity. 
In  such  cases  it  may  be  necessary  to  give  an  anaesthetic  and 
to  explore  deeply  at  several  points  over  the  dull  area.  The 
rules  of  procedure  are  the  same  as  for  simple  effusion  (see 
p.  no). 

If  pus  be  obtained,  there  is  still  the  possibility  in  exceptional 
cases  of  the  abscess  cavity  being  in  the  lung  instead  of 
in  the  pleura.  Or,  again,  it  may  be  a  subphrenic  or  a  liver 
abscess  pushing  up  the  diaphragm,  and  thus  encroaching 
upon  the  thoracic  space,  and  leading  to  collapse  of  the  base 
of  the  lung.  Complete  dulness  of  note  up  to  the  angle  of 
the  scapula,  or  even  higher,  with  weakened  or  bronchial 
breath-sound  and  diminished  vocal  vibrations,  may  be  thus 
produced,  whilst  the  heart  is  not  infrequently  displaced.  If 
the  exploring  needle  be  inserted  in  the  axillary  region 
through  the  sixth  or  seventh  space,  pus  will  very  probably  be 
evacuated,  the  needle  passing  through  the  displaced  dia- 
phragm and  striking  the  fluid  below  it.  We  can  recall  a  case 
of  this  kind  in  which  complete  dulness  extended  up  to  one 
inch  above  the  angle  of  the  right  scapula,  accompanied  by 
weak  bronchial  breathing  and  diminished  vocal  vibrations, 
and  in  which  the  apex-beat  of  the  heart  was  in  the  fifth  space, 
ij  inches  outside  the  nipple  line.  Forty-seven  ounces  of  pu§ 
were  withdrawn,  under  the  impression  that  the  case  was  one 
of  empyema.  It  was  only  when  resection  was  performed 
later,  and  when  the  pleura  was  found  to  be  free  from  fluid  and 
the  diaphragm  bulging  into  the  pleural  cavity,  that  the  true 
nature  of  the  disease  was  revealed.  In  this  case  an  X-ray 
examination  would  have  been  of  value. 

The  observer  may  suspect  the  presence  of  subphrenic 
abscess  (which  may,  however,  be  complicated  by  the  presence 
of  a  pleural  effusion)  if,  in  addition  to  the  physical  signs  of 
fluid  in  the  pleura,  abdominal  symptoms,  such  as  tenderness 
and  distension  over  the  region  of  the  liver,  or  oedema  of  the 
skin  in  this  situation,  be  present.  But  sometimes,  as  in  the 
case  above  referred  to,  these  are  absent,  and  the  diagnosis  is 


SUPPURATIVE  PLEURISY  12/ 

only  effected  when  the  position  of  the  pus  is  accurately  located 
by  surgical  intervention.  As  a  rule,  the  previous  history  and 
the  presence  of  abdominal  symptoms  will  suggest  a  special 
scrutiny  in  such  cases.  For  a  consideration  of  the  condition 
known  as  pyo- pneumothorax  subphrenicus,  when  the  abscess 
cavity  beneath  the  diaphragm  contains  air  as  well  as  pus,  we 
must  refer  the  reader  to  the  next  chapter  (see  p.  149). 

Prognosis. — From  what  we  have  said  as  to  the  aetiology  of 
empyema,  it  will  be  evident  that  the  prognosis  of  a  case  must 
depend  to  a  great  extent  upon  the  cause.  Thus  it  is  clear 
that  an  empyema  complicating-  a  case  of  puerperal  infection 
must  have  a  different  outlook  to  that  of  one  occurring  in  a 
patient  previously  in  g-ood  health.  In  the  latter  case  the 
prognosis  is  nearly  always  favourable,  provided  that  adequate 
surgical  treatment  be  early  resorted  to;  but  the  longer  this  is 
delayed  the  more  grave  does  the  outlook  become,  as  regards 
both  the  immediate  safety  of  the  patient  and  his  chance  of 
complete  recovery. 

In  cases  of  empyema  following  pneumonia  or  typhoid  fever 
the  prognosis  is  generally  satisfactory,  partly  perhaps  because 
such  cases  are  as  a  rule  detected  and  treated  early. 

In  children  the  prognosis  depends  to  some  extent  upon  the 
age,  the  mortality  increasing  as  the  age  of  the  child 
diminishes.  In  all  cases  the  prognosis  of  a  pneumococcic 
pleurisy  is  better  than  that  of  one  of  streptococcal  origin. 

Treatment. — The  treatment  of  suppurative  pleurisy  does 
not  differ  essentially  from  that  of  other  purulent  collections. 
The  pus  must  be  evacuated  as  speedily  and  thoroughly  as 
possible,  and  its  reaccumulation  prevented  by  the  provision  of 
free  drainage.  This  should  be  effected  by  the  incision  of  an 
intercostal  space,  or  by  the  resection  of  a  rib.  If  the  effusion 
be  very  large,  it  is  wise  as  a  preliminary  to  incision  to  remove 
a  portion  of  the  fluid  by  aspiration,  since  the  sudden  evacua- 
tion of  a  large  quantity  of  Uquid  may  sometimes  produce  fatal 
syncope. 

The  operation  for  empyema  should  never  be  performed 
without  first  inserting  the  exploring  syringe.  For  lack  of 
this  precaution  we  have  known  a  rib  resected  in  a  case  which 
proved  to  be  a  rapidly-growing  sarcoma  of  the  lung,  which 
had  worked  its  way  to  the  surface  and  suggested  a  case  of 
pointing  empyema. 


128  DISEASES   OF  THE  LUNGS   AND  PLEURAE 

Should  the  collection  be  small,  the  incision  must  be  made, 
immediately  over  the  seat  of  the  localising  puncture.  But  in  the 
case  of  an  empyema  filling  to  a  large  extent  the  general  pleural 
cavity,  the  site  chosen  should  be  over  the  ninth  rib,  just  out- 
side the  angle  of  the  scapula.  Here,  as  Sir  Rickman  Godlee'' 
has  pointed  out,  owing  to  the  adhesion  of  the  diaphragm  to  the 
lower  ribs  the  opening  soon  leads  into  the  most  dependent 
portion  of  the  pleural  cavity,  and  satisfactory  drainage,  both 
in  the  sitting  and  lying  posture  is  secured. 

Whether  incision  alone  or  incision  coupled  with  resection 
of  a  portion  of  a  rib  should  be  performed  is  a  matter  on 
which  there  is  some  difference  of  opinion.  In  our  own  view 
resection  is  as  a  rule  to  be  preferred,  since  when  incision  is 
alone  resorted  to,  the  drainage-tube  frequently  becomes 
nipped  from  the  falling  together  of  the  ribs ;  but  if  in  a  given 
case  the  patient  be  very  ill,  and  the  avoidance  of  shock  all- 
important,  we  should  not  hesitate  to  advise  a  simple  incision. 
On  the  other  hand,  if  the  side  be  fallen  in  and  the  intercostal 
spaces  much  diminished,  resection  is  absolutely  necessary. 

The  anaesthetic  given  should  be  gas  and  oxygen  or  chloro- 
form, not  ether,  the  latter  being  rarely  suitable  in  cases  of 
chest  disease,  owing  to  the  irritation  of  the  respiratory  pas- 
sages which  it  so  frequently  produces. 

In  performing  resection  an  incision   some  two   to   three 
inches  in  length  should  be  made  along  the  course  of  the  rib 
selected  down  to  and  including  the  periosteum.     This  should 
then  be  separated  from  the  rib  by  a  suitable  raspatory,  and 
about  two  inches  of  the  rib  removed  by  bone  forceps.   Having 
stanched  all  bleeding,  the  knife  is  then  inserted  through  the 
costal  pleura,  the  artery  being  carefully  avoided,  and  the  inci- 
sion freely  enlarged  by  the  introduction  of  the  finger  or  by 
opening  out  the  blades  of  a  dressing  forceps.     The  pus  there- 
upon escapes.     The  extent  of  the  abscess  cavity  should  be 
examined  by  the  finger,  and  any  large  masses  of  lymph  which 
may  be  loose  and  within  reach  should  be  removed.     If  the 
chloroform  be  now  sufficiently  slackened,  without  allowing 
the  patient  to  become  quite  conscious,  the  irritation  of  the 
pleura  by  the  finger  or  by  the  admission  of  cool  air  will  give 
rise  to  considerable  coughing,  which  is  most  salutary  in  lead- 
ing to  the  more  sffectual  expulsion  of  such  coagula  before 
the  introduction  of  the  drainage-tube.     After  the  operation 


SUPPURATIVE   PLEURISY  1 29 

a  thick  dressing  should  be  applied,  and  the  patient  returned 
to  bed. 

Washing  out  the  pleural  cavity,  whether  at  the  time  of  the 
operation  or  subsequently,  is  not  as  a  rule  to  be  recom- 
mended. It  is  rarely  required,  because  after  free  drainage 
even  foetid  empyemata  rapidly  cease  to  be  offensive;  it  is  not 
to  be  recommended,  except  in  the  rare  event  of  the  pus 
remaining  foetid,  because  the  procedure  is  not  devoid  of 
danger,  instances  of  sudden  death  from  pleural  shock  having 
been  recorded,  though  the  recent  experiences  of  war  surgery 
would  suggest  that  this  danger  has  been  exaggerated.  Should 
the  special  circumstances  of  a  given  case  require  its  use,  care 
must  be  taken  that  the  irrigation  be  performed  very  gently, 
the  danger  to  the  patient  being  in  this  way  materially 
diminished.^  In  some  cases,  especially  in  children,  immersion 
in  a  warm  iodine  bath  (3i.  of  the  strong  tincture  of  iodine 
to  the  gallon  of  water,  so  that  the  liquid  assumes  a  light 
sherry  colour)  may  be  employed  as  a  safe  and  satisfactory 
method  of  irrigating  the  pleura. 

The  after-treatment  of  the  case  is  of  great  importance,  the 
same  antiseptic  precautions  being  necessary  until  complete 
closure  of  the  wound  is  effected. 

During  convalescence,  to  assist  expansion  of  the  lung, 
various  breathing  exercises  may  be  performed.  The  attempt 
to  expand  collapsed  and  adherent  lung  sometimes  advocated, 
by  blowing  against  resistance  is  contrary  to  Nature's  method, 
and  unless  very  gently  employed  tends  to  produce  emphysema 
rather  than  healthy  lung  expansion.  Mild  calisthenics  and 
breathing  exercises  carefully  carried  out,  and  mountain  air 
are  to  be  advised. 

In  some  cases  in  which  the  lung  is  diseased,  or  the  empyema 
has  been  too  long  neglected,  the  lung  may  fail  to  expand. 
The  chest  wall  then  falls  in  to  some  extent,  but,  being  unable 
to  meet  the  lung,  a  large  pus-secreting  cavity  remains.  In 
cases  which  are  not  tuberculous  in  nature,  expansion  of  the 
lung  may  sometimes  be  effected  by  the  operation  devised  by 
M.  Delorme,'  and  known  as  Decortication  of  the  Lung. 
This  consists  in  the  removal  of  sufficient  area  of  rib,  and  the 
peeling  off  of  the  layers  of  false  membrane  which  overlie  the 
visceral  pleura  and  bind  down  the  lung,  thus  enabling  it  to 
expand,  which  it  sometimes  does  with  great  rapidity. 

9 


130  DISEASES   OF   THE   LUNGS   AND   PLEUR/E 

Should  decortication  prove  impossible,  some  form  of 
thoracoplasty  must  be  undertaken.  This  operation  consists  in 
removing  those  portions  of  the  ribs  which  bound  the  cavity, 
thus  allowing  the  chest  wall  to  be  brought  in  contact  with 
the  lung  surface.  Such  a  procedure  is  usually  termed  an 
Estlandcr  operation,'"  though  the  distinguished  surgeon  of 
Helsingfors  was  not,  as  a  matter  of  fact,  the  first  to  perform 
it.  Should  the  parietal  pleura  bounding  the  cavity  be  found 
densely  thickened  and  cartilaginous  in  hardness,  the  pleura 
and  intercostal  muscles  should  be  removed  as  well  (Schede's 
operation) :  the  overlying  soft  parts  then  fall  in,  and  con- 
stitute in  future  the  non-rigid  chest  wall  over  the  area 
dealt  with.  Such  operations  lead  to  much  deformity,  .  and 
naturally  vary  much  in  severity,  according  to  the  size  of  the 
cavity  to  be  dealt  with.  In  the  more  serious  cases  it  may  not 
be  possible  to  do  all  that  is  required  at  a  single  operation. 
But  if  the  lung  shows  no  sign  of  expanding,  if  the  cavity  be 
large,  the  discharge  considerable,  and  the  patient's  general 
strength  permits,  operative  interference  on  the  above  lines  is 
to  be  advised.  From  it  improvement  generally  results  and, 
not  infrequently,  recovery,  in  cases  which  would  otherwise 
steadily  go  downhill. 

Should  only  a  small  sinus  remain,  an  attempt  may  be  made 
to  hasten  its  closure  by  placing  the  patient  upon  open-air 
lines  of  treatment  or  by  a  stay  at  some  breezy  East  Coast 
resort,  such  as  Margate,  before  proceeding  to  more  drastic 
measures  of  treatment.  Closure  of  the  sinus  may  sometimes 
be  accelerated  by  the  employment  of  a  few  doses  at  weekly 
intervals  of  a  vaccine  prepared  from  the  specific  organism 
originating  the  disease. 

In  the  rare  cases  of  double  empyemata'^  it  is  well  at  first 
while  incising  one  pleura,  to  perform  aspiration  only  upon  the 
other.  In  this  way  time  may  be  gained,  and  the  more  radical 
treatment  of  the  opposite  empyema  undertaken  at  a  later 
date,  if  it  becomes  necessary.  Nevertheless,  we  have  seen  the 
two  radical  operations  successfully  performed  within  a  very 
few  days  of  one  another. 

Such  is  the  line  of  treatment  which  we  should  usually 
recommend  in  cases  of  empyema.  In  the  recent  epidemic 
of  injluenza,  however,  numerous  cases  of  empyema  were  met 
with   during  the  acute   stage  of  the  disease,  and  associated 


SUPPURATIVE   PLEURISY  I31 

with  an  underlying  broncho-pneumonia.  Most  of  these  were, 
as  we  have  indicated,  streptococcal  in  nature,  and  the  pus 
thin,  watery,  and  blood-stained,  and  in  some  cases  only  to  be 
recognised  as  pus  by  the  formation  of  a  deposit  on  standing, 
which  proved  microscopically  to  consist  of  polymorphonuclear 
leucocytes.  The  patients  were  for  the  most  part  exceed- 
ingly ill  from  influenza,  and  the  mortality  following  re- 
section and  drainage  was  high.  Aspiration,  repeated  when 
necessary,  proved  more  successful  in  these  exceptional  cases. 
We  had  one  case  also  under  our  care  in  which,  after  aspiration 
had  been  considered  and  negatived,  the  fluid  was  spontaneously 
absorbed,  and  the  patient  made  a  complete  recovery. 

The  treatment  of  empyema  occurring  in  the  course  of  pul- 
monary phthisis  requires  careful  thought  in  each  individual 
case.  The  lung,  being  diseased,  does  not  expand  when  the 
fluid  is  removed  so  readily  as  a  healthy  lung;  and,  again,  there 
is  reason  to  believe  that  the  pressure  exerted  by  the  fluid  upon 
the  lung  diminishes  its  blood-supply,  and  tends  to  check  the 
further  spread  of  the  tuberculous  disease.  We  shall  not  be 
so  ready,  therefore,  to  proceed  to  operative  treatment  with- 
out first  considering  all  the  circumstances.  If  the  bacterio- 
logical examination  prove  the  empyema  to  be  pyogenic  in 
nature,  and  if  it  be  acute  in  type,  incision  or  resection  must 
be  performed.  If,  on  the  other  hand,  the  pulmonary  disease 
is  extensive,  and  the  empyema  cause  but  slight  symptoms, 
then  it  will  be  wise  to  forbear,  resorting  to  aspiration  from 
time  to  time,  as  occasion  demands. 

In  cases  of  true  tuberculous  empyemata,  which,  as  we  have 
seen,  are  mostly  of  chronic  type  and  of  fair  prognosis,  ex- 
perience shows  that  operative  treatment  may  lead  to  hectic, 
and  but  hasten  the  end.  An  occasional  paracentesis,  with  or 
without  oxygen  replacement^-  (see  p.  114),  should  therefore, 
as  a  rule,  be  our  hue  of  treatment  in  these  cases,  and  it  is 
gratifying  to  note  how  slowly  the  fluid  sometimes  returns. 

REFERENCES. 

'  Article  on  "  Diseases  of  the  Pleura,"  by  Frederick  T.  Lord,  M.D., 
A  System  of  Medicine,  edited  by  William  Osier,  M.D.,  F.R.S.,  and  Thomas 
McCrae,  M.D.,  F.R.C.P.,  vol.  iii.,  p.  833.     London,   1908. 

^  "  Maladies  de  la  Plevre,"  par  le  Dr.  Netter,  Traite  de  Medecine, 
publiee  sous  la  direction  de  MM.  Bouchard  et  Brissaud,  deuxieme  edition, 
tome  vii.,  p.  442.     Paris,  igoi. 


132  DISEASES   OF    IHE   LUNGS   AND   PLEUR.E 

'  "  Sulla  transmissione  dei  suoni  attraverso  i  liquid!  endopleurici  di 
differente  natura,"  by  Dr.  Baccelli,  Archivio  di  Medicina,  Chirurgia  ed 
Igiena,  1875.  For  a  critical  reference  to  Dr.  Baccelli's  paper,  see  Dr. 
Gueneau  de  Mussy,  UUnion  Medicale,  Paris,  1876,  p.  3,  etc. 

*  For  additional  information  on  this  matter,  see  "  Note  on  the  Value  of 
Baccelli's  Sign — Pectoriloquie  Aphonique — in  the  Differential  Diagnosis 
of  Pleural  Effusions,"  by  R.  Douglas  Powell,  M.D.,  Transactions  of  the 
International  Medical  Congress,  vol.  ii.,  p.   141.     London,  1881. 

*  "  Tuberculous  Pleurisy,"  being  the  Shattuck  Lecture  of  the  Massa- 
chusetts Medical  Society  for  1893,  by  William  Osier,  M.D.,  p.  25.  Boston, 
1893.     (See  Collected  Reprints,  Third  Series,  by  William  Osier,  M.D.) 

*  See  The  Surgery  of  the  Chest,  by  Stephen  Paget,  M.A.,  F.R.C.S., 
p.  227.     Bristol  and  London,  1896. 

'  "  Discussion  on  the  Surgery  of  the  Thorax,"  opened  by  Rickman  J. 
Godlee,  M.S.,  F.R.C.S.,  British  Medical  Journal,  1S92,  vol.  ii.,  p.  828. 

*  For  a  further  consideration  of  this  subject,  see  The  Surgery  of  the 
Chest,  by  Stephen  Paget,  M.A.,  F.R.C.S.,  pp.  259-264.  Bristol  and 
London,  1896. 

°  (a)   "  Du  Traitement  des  Empyemes  Chroniques  par  la  Decortication 

du    Poumon,"    par    le    Dr.    Edmond    Delorme    (de    Paris),    Congres 

Franfais  de  la  Chirurgie,  10,  1896,  p.  379. 
[b]  "  Note  sur  les  Indications  de  la  Decortication  Puknonaire,"  par 

M.  Delorme,  Revue  de  la  Chirurgie,-  vol.  xxiv.,  1901,  p.  551. 
{c)  See  also  "  Chronic  Empyema  :   the  Value  of  Decortication  of  the 

Lung,"  by  W.  H.  Battle,  F.R.C.S.  (with  Bibliograhpy),  The  Lancet, 

1917,  vol.  i.,  p.  373. 
(d)   "  Surgery  of  the  Lung   and   Pleura,"   by   H.    Morriston   Davies, 

M.A.,  M.D.,  M.C.,  F.R.C.S.,  p.  79.     London,  1919. 

'•  "  Resection  des  Cotes  dans  I'Empyeme  Chronique,"  par  le  Professeur 
J.  A.  Estlander  (d'Helsingfors),  Revue  Mensuelle  de  Midecine  et  de 
Chirurgie.     Paris,  1879,  pp.  157  and  885. 

"  For  references  to  several  cases,  see  "A  Case  of  Double  Empyema, 
Simultaneous  Drainage  of  the  Pleural  Cavities  :  Recovery,"  by  Sidney 
Coupland,  M.D.,  and  A.  Pearce  Gould,  M.S.,  Transactions  of  the  Clinical 
Society  of  London,  1891,  p.  79. 

'=   [a)   "  Surgery  of  the  Lung   and   Pleura,"   by  H.    Morriston   Davies 
M.A.,  M.D.,  M.C.,  F.R.C.S.,  p.  46.     London,   1919. 
(*)  "  Pneumothorax  Treatment  of  Pulmonary  Tuberculosis,"  by  Clive 
Riviere,   M.D.,   F.R.C.P.,  p.    145.     London,    1917. 


CHAPTER  IX 

PNEUMOTHORAX 

Hydro-  and  Pyo-Pneumothorax. 

This  disease  was  practically  unknown  until  Itard/  in  the 
year  1803,  drew  attention  to  it  in  his  graduation  thesis  at  the 
University  of  Paris,  and  designated  it  "  pneumothorax."  The 
succussion  splash,  it  is  true,  was  known  to  the  writers  of 
antiquity,  but  Hippocrates  and  his  disciples  regarded  it  as 
a  physical  sign,  not  of  air  in  the  pleura,  but  of  empyema.'^ 
In  the  Middle  Ages,  though  certain  writers  refer  to  the  occa- 
sional presence  of  air  in  the  pleural  cavity,  the  occurrence  was 
regarded  as  a  phenomenon  rather  than  as  a  definite  disease. 
The  credit  must,  therefore,  be  given  to  Itard  for  his  recog- 
nition of  the  malady,  and  for  emphasising  its  connection  with 
tuberculosis.  It  was  Laennec,  however,  who  first  rendered 
its  diagnosis  easy,  and  his  name  must  ever  be  associated  with 
the  disease. 

.etiology. — Laennec^  believed  that  pneumothorax  might 
be  both  non-perforative  and  perforative  in  nature.  In  the 
former  case,  termed  "simple"  or  "essential"  pneumothorax, 
he  thought  that  the  air  was  either  secreted  by  a  perfectly 
healthy  pleura,  or  was  the  result  of  decomposition  of  fluid, 
generally  purulent  in  nature,  previously  effused  into  the 
pleural  cavity.  But  such  cases  he  regarded  as  somewhat 
rare,  and  he  believed  that  the  commonest  cause  of  the  con- 
dition was  the  softening  of  a  superficial  tubercle  or  the  rup- 
ture of  a  vomica,  whereby  a  communication  between  a 
bronchus  and  the  pleural  cavity  was  established,  thus  leading 
directly  to  the  entrance  of  air. 

These  views  were  for  a  time  accepted,  but  in  an  able  article 

"  Not    to   recognise   when   practising    succussion    the   presence   of    an 
empyema  .   .   .  shows  a  lack  of  skill  ''  (Hippocrates,  De  Morbis,  i.,  §  6). 


134  DISEASES    OF   THE  LUNGS   AND   PLEURA 

in  the  Gazette  Hehdomadaire  for  1864  Jaccoud  maintained 
that  there  was  no  sufficient  proof  of  the  occurrence  of  pneu- 
mothorax from  the  secretion  of  air  through  a  healthy  pleura, 
and  expressed  serious  doubts  as  to  the  presence,  save,  per- 
haps, very  occasionally,  of  air  in  the  pleura  derived  from  the 
decomposition  of  liquid  effusions.  Jaccoud  contended  that  in 
cases  of  so-called  "  simple  "  or  "  essential  "  pneumothorax  a 
minute  perforation  of  the  pleura  probably  occurred,  the  aper- 
ture of  which  had  subsequently  closed.  There  can  be  little 
doubt  that  this  criticism  is  just,  and  that — ^apart  from  gun- 
shot wounds  of  the  chest,  in  which,  as  we  shall  see  (p.  160), 
hsemopneumothorax  is  common,  the  air  being  often  then 
produced  by  the  growth  of  anaerobic  gas-forming  organisms 
introduced  with  the  bullet  or  by  fragments  of  clothing — 
pneumothorax  is  nearly  always  perforative  in  character. 

The  conditions  under  which  a  rupture  of  the  pleura  and  the 
formation  of  pneumothorax  may  occur  are  very  varied.  The 
following  table,  giving  the  results  obtained  by  Biach^  from 
an  analysis  of  918  cases  in  the  hospitals  of  Vienna,  shows 
what  the  conditions  are,  and  roughly  their  relative  frequency  : 

Pulmonary  tuberculosis       ...             ...             ...  ...  715 

Gangrene  of  the  lung          ...            ...            ...  ...  65 

Empyema                  ...             ...             ...             ...  ...  4c 

Wounds 

Bronchiectasis         ...  ...  ...  ... 

Abscess  of  the  lung 

Emphysema              ...             ...             ...             ...  ...  7 

Breaking  down  of  haemorrhagic  infarct       ...  ...  4 

After   paracentesis                 ...             ...             ...  ...  , 

Hydatid  of  the  lung            ...             ...             ...  ...  i 

Rupture  of  bronchial  gland  into  bronchus  and  pleura  i 

Caries  of  the  ribs                 ...             ...             ...  ...  ^ 

Caries  of  the  sternum          ...             ...             ...  ...  j 

Abscess  of  the  mamma        ...             ...             ...  ...  j 

Perforation  of  the  oesophagus            ...             ...  ...  2 

Perforation  of  a  gastric  ulcer  into  the  pleura  ...  2 

Rupture  of  hydatid  of  liver  into  colon  and  pleura     ...  i 
Rupture    into   the   pleura   of    a   sacculated   peritoneal 

effusion                  ...             ...             ...             ...  __  j 

Cause  undetermined            ...            ...            ...  ...  16 

Total  number  of  cases      ...  ...  ...  gig 

The  above  figures  refer  to  civil  life  and  demonstrate  clearly 
that,  excluding  gangrene  of  the  lung,  wounds  of  the  chest, 
and  the  discharge  of  empyemata,  it  is  rare  for  pneumothorax 
to  occur  from  any  other  cause  than  the  breaking  down  of 
subpleural  areas  of  tuberculous  consolidation.     It  is  doubt- 


32 
10 


PNEUMOTHORAX  1 35 

fill,  indeed,  whether  the  figure  77'8  per  cent,  estimated  by 
Biach  really  does  justice  to  the  great  predominance  of 
phthisis.  Possibly  90  per  cent.,  as  given  by  other  writers,  is 
a  truer  estimate.  In  the  recent  war  shell  and  gunshot  wounds 
of  the  chest  naturally  took  the  chief  place  in  the  aetiology. 

In  regard  to  empyema,  it  should  be  noted  that  in  by  no 
means  every  case  in  which  perforation  of  the  lung  occurs  does 
pneumothorax  result.  This  is  accounted  for  by  the  viscid 
pus  which  obstructs  the  bronchus,  and  perhaps  by  the  often 
fistulous  character  of  the  opening  which  impedes  the  entry 
of  air. 

The  cohesion  of  the  pleural  surfaces,  like  that  of  any  other 
plane  surfaces  in  airtight  application,  is  very  considerable*; 
hence,  when  both  pleurae  are  wounded,  as  by  a  fractured  rib 
or  perforation  from  without,  the  air  will  not  infrequently 
escape  from  the  lung  into  the  subcutaneous  cellular  tissue  of 
the  thoracic  wall  rather  than  into  the  pleural  cavity. 

In  whooping-cough  rupture  of  the  lung  is  occasionally  pro- 
duced by  the  violent  expiratory  efforts  characteristic  of  the 
disease.  But  in  these  cases  the  pleura  generally  remains 
intact  and  the  air  is  effused  into  the  subpleural  tissue  of 
the  lung,  sometimes  finding  its  way  eventually  into  the  cellu- 
lar tissue  of  the  neck  and  chest  walls.  Subcutaneous  emphy- 
sema, not  pneumothorax,  thus  as  a  rule  ensues.  To  this  class 
would  probably  belong  the  case  of  a  young  lady  who,  during 
an  attack  of  asthma,  was  found  by  one  of  us  to  have  emphy- 
sematous crackling  throughout  the  cellular  tissue  of  the  neck, 
pectoral  region  and  back. 

Another  cause  of  pneumothorax  to  which  we  may  refer  is 
emphysema.  Cases  referable  to  this  disease  are  undoubtedly 
rare,  but  a  few  verified  by  post-mortem  examination  are  on 
record.  In  the  case  recorded  by  Sir  J.  Kingston  Fowler®  the 
patient  died  suddenly  shortly  after  labour,  and  at  the  autopsy 
no  sign  of  tubercle  was  found,  but  only  a  ruptured  emphyse- 
matous bulla.  Similarly,  in  the  case  described  by  Dr.  Ran- 
king,^ in  which,  three  months  after  recovery  from  pneumo- 
thorax, death  occurred  from  a  ruptured  dissecting  aneurism 
of  the  aorta,  no  lesion  in  the  lung  except  emphysema  could 
be  seen.  These  cases  are,  however,  exceptional,  and  we 
must  not  assume  when  pneumothorax  occurs  suddenly,  and 
in  the  absence  of  physical  signs  of  disease  of  the  lung,  that  a 


136  DISEASES    OF  THE  LUNGS   AND   PLEURA 

ruptured  emphysematous  bulla  has  been  the  cause.  In  the 
great  majority  of  such  cases  a  minute  tuberculous  lesion  has 
been  present,  and  to  its  rupture  we  must  trace  the  com- 
plication. 

Tuberculous  Pneumothorax. 

The  constant  breaking  down  of  caseous  material  in  the 
course  of  phthisis  tends,  by  undermining  the  pleura  and  inter- 
rupting its  vascular  supply  at  certain  points,  to  cause  it  to 
soften  and  to  give  way  as  the  result  of  some  trifling  increase 
of  air-pressure  during  cough  or  effort.  The  perforation  may 
occur  at  any  period  of  the  disease;  even  at  the  very  com- 
mencement a  small  subpleural  tubercle  may  soften  and  break 
through  the  pleura,  but  such  an  occurrence  is  much  more 
common  in  the  later  stages. 

In  the  majority  of  cases  of  pulmonary  tuberculosis,  pleurisy 
of  a  dry  and  adhesive  kind  accompanies  and  keeps  pace  with 
the  progressing  lung  consolidation.  But  it  may  be  observed 
post-mortem  in  some  cases  which  are  marked  by  acuteness  of 
process,  and  by  the  pneumonic  character  of  the  consolida- 
tions, that  no  adhesion  between  the  pleural  surfaces  has  taken 
place,  each  surface — the  visceral  pleura  more  especially — 
being  covered  by  a  thin  finely  granular  semi-transparent  layer 
of  lymph,  which  may  readily  be  scraped  off  with  a  knife,  leav- 
ing the  shining,  almost  healthy-looking  pleura  denuded.  At 
certain  points  of  the  surface  thus  affected  will  be  seen  opaque 
yellow  spots,  varying  in  size  from  that  of  a  pin's  head  to  that 
of  a  bean,  some  close  to  the  pleura,  others  more  dimly  seen 
through  it  (Plate  IV.).  On  making  a  vertical  section  through 
such  an  opacity,  we  divide  a  more  or  less  softened  caseous 
nodule,  having  its  centre,  perhaps,  already  excavated.  It  is  at 
some  one  or  more  of  these  points  that  the  pleura  most  com- 
monly gives  way. 

Pneumothorax  is  thus  most  likely  to  occur  in  the  more 
acute  pneumonic  forms  of  phthisis,  and  least  so  in  the  more 
chronic  fibroid  varieties  of  the  disease.  Nevertheless,  it  is 
som.etimes  met  with  in  the  latter,  and  it  was  pointed  out  by 
one  of  us'  that  sinuses,  in  no  respect  differing  from  those 
which  originate  from  chronic  abscesses  or  carious  bone,  may 
sometimes  be  found  extending  from  old  cavities  towards  the 
surface.      Such    sinuses    may    penetrate    both    layers    of    the 


PLATE  IV 


PNEUMOTHORAX 

The  drawing  shows  the  posterior  portion  of  the  lower  lobe  of 
the  left  lung.  Over  the  upper  lobe  the  pleural  layers  ars 
adherent,  and  at  A  the  parietal  layer  is  shown  cut  across  and 
having  its  edge  turned  back.  Two  inches  below  the  apex  of  the 
lower  lobe,  at  B,  the  visceral  pleura  is  seen  to  be  thin  and 
necrotic,  and.  in  the  centre  a  perforation  has  occurred,  the 
aperture  of  which  admitted  a  small  probe.  At  C  the  pleura  is 
also  becoming  necrotic. 

From  a  girl  aged  sixteen,  who  died  from  acute  caseous  tuber- 
culosis of  four  months'  duration.  The  pneumothorax  gave  no 
sign  during  life,  and  was  discovered  at  the  autopsy.  The  pleural 
cavity  contained  air  and  three  ounces  of  clear  serous  fluid. 


(From  the  Erompton  Hospital  Museum.     Natural  size.) 


PLATE  IV 


•Sj+SeW'j^ 


Pneumothorax,  showing  Small  Point  of  Rupture  in  Pleura. 


To  face  p.  136. 


PNEUMOTHORAX 


137 


pleura,  and  open  into  the  subcutaneous  cellular  tissue  of  the 
thoracic  wall,  or  if,  as  is  rarely  the  case,  the  pleura  be  not 
firmly  adherent,  a  communication  with  the  pleural  cavity 
becomes  established.  In  one  remarkable  case  described  in 
the  paper  referred  to  a  sinus  had  opened  from  an  old  cavity 
through  the  posterior  mediastinum  into  the  opposite  pleural 
space.  When  a  communication  is  thus  effected  between  a 
more  or  less  deep-seated  vomica  and  the  pleural  surface,  the 
perforation  is  so  oblique  or  sinuous  as  to  be  always  prac- 
tically valvular. 

Concerning  the  frequency  of  pneumothorax  occurring  in 
the  course  of  well-marked  phthisis,  we  may  state  that  of 
1,069  post-mortem  examinations  on  this  disease  made  at  the 
Brompton  Hospital  during  the  years  1887-1894,  88,  or  8-2 
per  cent,  showed  this  lesion.^'  Our  own  post-mortem  figures 
at  the  same  hospital  during  the  three  years  1900-1903 
yielded  a  somewhat  lower  result,  pneumothorax  being 
observed  in  17  out  of  263  cases,  giving  a  percentage  of 
6-4.*''  Allowing  for  the  extra  zeal  with  which  permission  for 
an  autopsy  is  naturally  sought  in  an  interesting  case,  we  shall 
probably  not  greatly  err  if  we  assume  that  some  6  per  cent, 
of  all  cases  of  phthisis  die  with  pneumothorax. 

The  complication  occurs  somewhat  more  frequently  on  the 
left  than  on  the  right  side,  the  figures  given  by  various  writers 
being  as  follows : 


Number  of 
Cases. 

Right  Side. 

I 
Left  Side. 

Louisio          

Walshe  (collected) i"         .'.'         '" 
Samuel  West^i 

The  Authors  10        ...         ..'. 

9* 
»»          *»                  ...         ... 

8 

85 
83 
39 
19 

I 

30 

41 
16 

7 

7 

55 

42 
23 

12 

234 

95 

139 

The  greater  vulnerability  of  the  left  lung  which  these 
figures  disclose  is  probably  only  in  conformity  with  the 
increased  frequency  with  which  this  lung  becomes  the  seat 
of  tuberculous  disease. 

The^  opening  into  the  pleura  is  generally  single,  but  if 
softenmg  is  taking  place  rapidly  two  or  more  perforations 


138  DISEASES    OF   THE   LUNGS   AND   PLEURA 

may  be  found.  Of  seventeen  autopsies  made  by  one  of  us, 
fourteen  showed  a  single  point  of  rupture,  two  a  double  per- 
foration, and  in  one  case  there  were  three.'*  More  rarely  the 
pleura  over  a  limited  area  has  been  found  necrotic  and  riddled 
with  holes.  As  a  rule  no  difficulty  is  experienced  in  finding 
the  perforation.  On  opening  the  chest  the  lung  is  seen  to 
be  collapsed  and  lying  along  the  vertebral  column,  though 
perhaps  with  its  apex  still  retained  by  adhesions  in  contact 
with  the  chest  wall.  The  surface  of  the  organ  is  lustreless 
and  somewhat  more  opaque  than  usual.  In  order  to  locate 
the  point  of  rupture,  the  pleural  cavity  should  be  filled  with 
water  and  air  pumped  into  the  trachea  by  means  of  a  pair  of 
bellows.  The  bubbling  out  of  the  air  at  once  reveals  the 
perforation. 

The  size  of  the  opening  varies  from  that  of  a  pin's  point  to 
a  threepenny-piece  (see  Plates  IV.  and  V.),  but  usually  it  is 
small  and  circular.  In  the  majority  of  our  own  observations 
the  aperture  admitted  only  a  small  probe,  but  in  two  cases  it 
was  the  size  of  a  pea  and  a  threepenny-piece  respectively.  On 
the  other  hand,  the  aperture  may  be  occasionally  linear  rather 
than  circular,  and  in  two  instances  which  we  have  recorded  it 
was  found  to  measure  respectively  i  and  J  inch  in  length.'* 

The  position  of  the  opening  is  very  variable.  It  is  usually 
found  in  the  upper  half  of  the  lung,  though  rarely  higher  than 
the  third  rib,  since  above  this  point  the  pleural  cavity  is  gen- 
erally obliterated  by  adhesions.  We  have  ourselves  seen  the 
perforation  nine  times  in  the  upper  lobe,  once  in  the  middle, 
and  eight  times  in  the  lower  lobe,  the  anterior,  the  axillary, 
and  posterior  aspect  of  the  lung  being  affected  with  nearly 
equal  frequency.  The  lowest  situation  in  which  we  have 
observed  the  rupture  has  been  the  centre  of  the  posterior 
aspect  of  the  lower  lobe. 

Whether  the  communication  with  the  pleura  be  patent  or 
valvular  is  a  matter  of  some  importance  as  regards  both 
symptoms  and  treatment.  If  the  opening  be  direct  and 
patent,  there  can  be  no  positive  air-pressure  within  the  pleura, 
since  no  air  can  be  pent  up  there.  By  means  of  a  trocar 
fitted  by  tubing  to  a  water-pressure  gauge  we  have  ascer- 
tained post-mortem  the  degree  of  intrapleural  pressure  in  six- 
teen cases  of  pneumothorax,^^'  and  in  four  out  of  these  the 
pressure   was   nil.     If,   on  the   other  hand,   the   opening  be 


PLATE  V 


« 


PNEUMOTHORAX 


139 


oblique  or  valvular,  although  during  inspiration  air  may  enter 
the  pleura,  yet  the  moment  the  air  in  the  pleura  is  compressed 
in  expiration  the  edges  of  the  oblique  opening  come  together, 
and  the  air  cannot  escape  at  all,  or  only  with  difficulty.  In 
twelve  cases  out  of  the  sixteen  above  mentioned  there  was  an 
intrapleural  pressure  present  varying  in  degree  from  if  to 
7  inches  of  water. 

The  gas  effused  into  the  cavity  of  the  pleura  resembles 
expired  air  in  so  far  that  it  contains  less  oxygen  and  more 
carbonic  acid  than  inspired  air,  but  it  varies  in  composition 
according  to  the  nature  of  the  opening.  John  Davy,"  in 
1823,  was  the  first  to  study  this  question,  and  in  a  series  of 
observations  on  a  case  of  pyo-pneumothorax  he  found  that 
the  carbonic  acid  reached  a  maximum  of  16  per  cent.,  while 
the  oxygen  fell  to  a  minimum  of  I'S  per  cent.  Other  analyses 
have  since  been  made,  and  notably  by  Ewald,"  who,  from  an 
examination  of  eighteen  cases,  concluded  that  the  nature  of 
the  perforation  could  be  gauged  from  the  percentage  of  car- 
bonic acid  present,  under  5  per  cent,  indicating  a  large  per- 
foration communicating  freely  with  a  bronchus,  5  to  10  per 
cent,  a  valvular  aperture,  and  10  per  cent,  or  higher  a  perfora- 
tion already  closed. 

These  conclusions  must  not  be  accepted  too  exactly,  but 
Ewald's  figures  are  interesting  as  showing  what  differences 
we  may  expect  to  find  in  the  composition  of  the  air  according 
as  its  escape  is  easy  or  more  or  less  impeded.  Two  extreme 
examples  may  be  quoted,  the  figures  for  inspired  and  expired 
air  being  added  for  comparison : 


Percentage 
of  CO2. 

Percentage 
ofO. 

Percentage 
ofN. 

Normal  inspired  air  ... 

Pneumothorax    with    open    pevfova- 

0-04 

20-8l 

79-15 

tion 
Normal  expired  air    ... 

Pneumothorax   with   closed  perfora- 

i'76 
4-38 

18-93 
16-033 

79-31 
79-587 

1 

tion 

1775 

9-95 

72-30      ; 

In  cases  of  foetid  pyo-pneumothorax  sulphuretted  hydrogen 
may  be  present,  sometimes  even  in  considerable  quantities 
(Duncan'^). 

The  first  effect  of  perforation  of  the  pleura  is  effusion  of 


140  DISEASES    OF  THE   LUNGS   AND   PLEURA 

air,  and  perhaps  the  escape  of  some  purulent  fluid  from  the 
ruptured  lung  into  the  pleural  cavity;  the  second  effect  is 
more  or  less  intense  pleuritis;  and,  thirdly,  if  the  patient  sur- 
vives, a  fluid  effusion  generally  follows.  This  is  usually  at 
first  serous,  but  it  becomes  opalescent,  and  may  finally  assume 
an  opaque  and  purulent  character.  For  a  considerable  time, 
however — possibly  for  some  weeks,  or  even  longer — the  sero- 
purulent  appearance  is  retained,  and  in  tuberculous  cases  this 
may  be  described  as  the  usual  appearance  of  the  liquid.  Such 
serous  or  sero-purulent  exudates,  when  tested,  are  found 
sterile;  but  inoculation  into  a  guinea-pig  rarely  fails  to  prove 
their  tuberculous  nature,  and  in  not  a  few  cases  tubercle 
bacilli  may  be  detected  in  the  sediment.  Occasionally  the 
liquid  may  be  truly  purulent  from  the  first,  pyogenic  micro- 
organisms having  obtained  access  to  the  pleural  cavity. 

The  following  table  shows  the  nature  of  the  effusion  in 
fifteen  cases  of  tuberculous  pneumothorax  observed  by  us, 
in  which  the  duration  could  be  approximately  gauged^*: 


Duration  of  Pneumothorax. 

Contents  of  Pleural  Cavity. 

A  few  hours 

...     Air  only. 

30  hours       

2  days 

,, 

2     ,.              

...     Air  with  sero-purulent  fluid 

6 ... 

...     Air  only. 

6 

...     Air  with  serous  fluid. 

2  weeks 

Some  weeks 

•  *  ■                      1  »                                 1 1 

...     Air  with  pus. 

At  least  5  weeks      

•  •                      )  )                     )  J 

2  months      

At  least  2  months 

•  •  •                     )  )                      1  > 

At  least  24  months 

...     Sero-purulent  fluid. 

4  months      

5       

7  ..            

8       

II            II 

.  •  •            >  > 
...     Air  with  pus. 

Symptoms.— In  speaking  of  the  symptoms  of  pneumo- 
thorax, we  have  especially  in  mind  that  most  coinmon  form 
due  to  perforation  of  the  pleura  in  the  course  of  tuberculous 
disease.  The  reader  will  easily  recognise  variations  from  this 
type.  In  well-marked  cases  the  principal  symptoms  are 
sudden  acute  pain  in  the  side,  followed,  or  rather  attended,  by 
great  dyspnoea  and  shock.  The  pulse  becomes  frequent, 
feeble  and  small,  the  respirations  relatively  more  frequent 
than  the  pulse,  and  the  voice  feeble  or  suppressed.  As  a 
result  of  the  shock,  just  as  in  perforation  of  the  intestine, 


PNEUMOTHORAX 


141 


the  temperature  of  the  body  may  fall.  But  such  a  primary 
fall  is  rarely  a  marked  feature,  and  is  very  often  absent. 
More  commonly  the  temperature  at  once  rises,  and  in  some 
cases  the  rise  is  rapid  and  marked,  forming  a  noticeable 
feature  of  the  temperature  chart  (see  Figs.  23  and  24). 
The  patient  is  often  conscious  of  "  something  having  given 
way,"  and  feels  a  peculiar  trickling,  cold  sensation,  associated 
with  the  pain  in  the  affected  side.     Occasionally,  also,  there  is 


Fig.  23. — Chart  illustrating  the  Rapid  Rise  of  Temperature  which  is 

OFTEN    associated    WITH    THE    DEVELOPMENT    OF    PNEUMOTHORAX. 

(From  a  male  patient,  J.  B.,  aged  twenty-one.) 


great  hyperassthesia  in  this  region.  The  patient  frequently 
changes  his  position :  he  may  sit  up  or  recline,  with  the  head 
raised,  and  with  an  inclination  to  the  sound  side,  or,  again, 
he  may  assume  the  sitting  posture  with  slight  inclination  for- 
wards, and  with  the  elbows  resting  upon  the  knees,  and  this 
is  the  position  most  commonly  chosen. 

There  is  nothing  absolutely  characteristic  about  these  symp- 
toms except,  perhaps,  the  suddenness  with  which  they  may 


M 


DISEASES   OF   THE  LUNGS    AND   PLEUR.E 


supervene;  but  in  marked  cases  the  alarmed,  anxious,  and 
distressed  countenance,  the  evident  urgency  of  the  dyspnoea, 
usually  amounting  to  orthopnoea,  and  the  small  whispering 
voice,  are  in  themselves  strikingly  suggestive.  All  the  symp- 
toms may,  nevertheless,  be  most  closely  simulated  in  an  attack 
of  acute  pulmonary  congestion  supervening  upon  already 
advanced  tuberculous  disease.  On  the  other  hand,  in  not  a 
few  cases,  and  especially  those  in  which  the  lung  affected  has 


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Fig.   24. — Chart   illustrating   the   Rapid   Rise   of   Temperature    which 

NOT    UNCOMMONLY    ACCOMPANIES    THE    OnSET    OF    PNEUMOTHORAX. 

(From  a  male  patient,  W.   H.,  aged  nineteen.) 


been  already  extensively  destroyed,  there  may  be  an  almost 
entire  absence  of  any  symptoms  to  mark  the  onset  of  the 
complication.  In  such  cases  disturbed  action  of  the  heart 
may  be  the  chief  trouble  of  which  the  patient  complains. 

Physical  Signs. — The  physical  signs  of  pneumothorax  are 
very  definite,  and  can  rarely  be  mistaken  for  those  of  any 
other  disease.  We  will  enumerate  the  chief  of  them,  and 
dwell  more  fully  upon  those  which  are  essentially  important. 


PNEUMOTHORAX 


143 


In  a  well-marked  case  the  affected  side  is  enlarged,  the 
shoulder  raised,  the  intercostal  spaces  effaced,  and  but  little 
or  no  movement  is  perceptible  with  respiration,  whilst  the 
opposite  side  labours  with  the  rapid  breathing,  its  soft  parts 
receding  with  each  inspiration.  The  heart  is  displaced 
towards  the  sound  side,  and  the  abdominal  organs  are 
depressed.  The  percussion  note  is  greatly  hyper-resonant  or 
truly  tympanitic,  where,  perhaps,  it  had  before  been  impaired. 
Respiratory  murmur  is  either  absent  or  very  feeble,  and  at 
one  or  two  points  more  or  less  distant  amphoric  breathing 
may  be  heard,  with  metallic  whisper  and  echo  on  coughing. 
Pectoriloquy  is  scarcely  ever  present.  Metallic  tinkling  may 
be  observed,  especially  after  cough.  Vocal  fremitus  is  either 
absent  or  much  diminished.  On  applying  the  stethoscope 
over  one  point  of  the  area  affected,  whilst  at  another  per- 
cussion is  made  with  coins  or  other  hard  substances,  a  pecu- 
liar ringing  sound,  the  bruit  d'airain  or  bell  sound  (see  p.  62), 
is  heard.  This  is  very  characteristic  of  pneumothorax, 
though  occasionally  also  heard  over  large  pulmonary  cavities. 

Later,  when  effusion  of  fluid  has  occurred,  there  is  dulness 
over  the  lower  portion  of  the  affected  side,  with  hyper-reson- 
ance above,  the  distribution  of  dulness  and  resonance  shifting 
with  the  altered  position  of  the  patient.  The  presence  of 
such  movable  dulness  is  highly  suggestive,  the  level  of  the 
fluid  in  a  case  of  simple  pleurisy  shifting  in  a  very  slight 
degree,  and  that  only  in  the  earlier  stages.  On  placing  the 
ear  against  the  chest,  and  giving  the  patient  a  somewhat 
abrupt  shake,  a  splashing  sound  may  be  distinctly  heard, 
which  is  very  characteristic  of  hydro-  or  pyo-pneumothorax.* 
This  "  succussion  splash  "  may  be  observed  in  cases  of  pneu- 
mothorax in  which  no  other  evidence  of  fluid  has  been  forth- 
coming. The  explanation  is  simple.  The  moment  pneumo- 
thorax occurs,  the  diaphragm  on  the  affected  side  becomes 
flaccid  and  more  or  less  concave,  being  drawn  downwards  by 
the  weight  of  the  abdominal  organs,  and  in  this  concavity  a 
certain  quantity  of  fluid  may  collect  without  yielding  per- 
cussion dulness.     In  cases  in  which  the  intrapleural  tension 

*  The  directions  given  in  the  Hippocratic  writings  for  eliciting  this 
sound  are  as  follows  :  "  Place  the  patient  on  a  firm  seat,  and  let  an 
assistant  hold  his  arms ;  then,  shaking  him  by  the  shoulders,  listen  on 
which  side  the  splash  is  heard  "  {De  Morbis,  ii.,  §  47). 


44 


DISEASES   OF   THE   LUNGS   AND   PLEUR/E 


Fig.    25. — Drawing   made  at  the  Autopsy   of  a   Case   of   Pyo-Pneumo- 

THORAX        with       MARKED        INTRAPLEURAL       PRESSURE,        SHOWING        THE 

Diaphragm  extending  down  to  the  Umbilicus,  and  forming  a 
Large  Abdominal  Tumour,  greatly  displacing  the  Liver  and 
Stomach.  When  the  Chest  was  punctured,  and  the  Air 
allowed  to  escape,  the  Diaphragm  became  relaxed,  and  the 
Tumour  disappeared. 


(Note.— The   drawing    was   made   from   near   the    feet,    and   the   chest    is 
accordingly  somewhat  foreshortened.) 


is  considerable  this  depression  of  the  diaphragm  may  become 
extreme.  Thus,  in  the  case  of  pyo-pneumothorax  illustrated 
in  Fig.  25  it  formed  a  large  sausage-shaped  tumour,  convex 


PNEUMOTHORAX  1 45 

towards  the  abdomen,  extending"  nearly  to  the  umbilicus,  and 
dislocating  the  liver  to  the  left.  On  puncturing-  the  chest  and 
allowing  the  air  to  escape,  the  diaphragm  became  relaxed, 
and  the  tumour  disappeared. 

In  cases  in  which  the  quantity  of  fluid  present  is  consider- 
able intercostal  fluctuation  may  sometimes  be  observed.  In 
other  cases,  on  sharply  percussing  immediately  below  the  line 
of  contact  of  resonance  and  dulness,  a  thrill,  significant  of 
fluid  vibrations,  may  be  detected. 

Such  are  the  signs  of  pneumothorax,  of  which  those  of 
cardinal  importance  are  the  following:  (i)  hyper-resonance; 
(2)  absent,  feeble,  or  amphoric  respiratory  sounds;  and  (3)  dis- 
placement of  the  heart.  These  three  signs  alone  are  suffi- 
cient to  render  the  diagnosis  certain,  and  their  presence  can 
be  ascertained  by  a  physical  examination,  which  will  not  add 
to  the  distress  of  the  patient.  Let  us  now  consider  each  of 
them  in  greater  detail : 

1.  The  degree  and  extent  of  the  hyper-resonance  depend 
upon  the  quantity  and  tension  of  the  air  that  has  escaped 
into  the  pleural  cavity.  The  note  has  usually  a  drum-like 
quality,  which  is  characteristic;  but  in  cases  in  which  the  ten- 
sion of  the  air  is  great  the  vibration  of  the  chest  walls  is  less 
free,  and  the  tympanitic  note  becomes  somewhat  deadened. 
The  boundaries  of  hyper-resonance  include  the  sternum,  and 
may  extend  beyond  it  towards  the  healthy  side;  if  the  left 
side  be  affected,  the  normal  cardiac  dulness  is  altogether 
effaced.  As  a  rule,  the  whole  lung-  is  collapsed,  save  per- 
haps at  the  summit,  where  there  are  frequently  some  old 
adhesions.  In  some  cases,  however,  adhesions  are  so  strong 
and  extensive  as  to  limit  the  pneumothorax  to  a  small  por- 
tion only  of  the  pleural  cavity — usually  the  base  or  the  lower 
anterior  and  axillary  region.  In  such  cases  of  "partial  pneu- 
mothorax " — and  they  are  by  no  means  uncommon,  nine  out 
of  our  nineteen  cases  being  of  this  type®* — the  hyper-reson- 
ance will  be  limited  to  the  corresponding-  portion  of  the  chest. 
As  the  symptoms  are  rarely  urgent  in  these  patients,  the  com- 
plication may  pass  unnoticed. 

2.  The  character  of  the  breath-sounds  varies  according  to 

the  nature  of  the  opening.     Over  the  greater  portion  of  the 

affected  side  the  respiratory  sounds  are  as  a  rule  annulled,  and 

where  the  opening  is  small  and  quite  valvular  no  auscultatory 

10 


146  DISEASES   OF  THE  LUNGS   AND  PLEURAE 

sounds  may  be  detected  at  any  point,  although  very  often, 
even  in  these  cases,  at  one  spot  a  faint  and  distant  hollow 
inspiratory  sound  may  be  heard  on  careful  auscultation.  In 
cases,  however,  in  which  the  opening  through  the  pleura  is 
free,  the  entry  and  exit  of  the  air  to  and  from  the  pleural 
cavity  gives  rise  to  a  variety  of  amphoric  breathing— not  loud, 
but  peculiarly  large  and  of  metallic  quality— which  can  rarely 
be  mistaken.  This  amphoric  breathing  is  most  audible  at 
some  one  portion  of  the  chest  nearest  to  the  seat  of  perfora- 
tion. It  is  commonly  best  heard  at  the  mammary  or  upper 
or  lower  scapular  region,  and  is  conducted  more  or  less  dis- 
tinctly from  this  point.  With  a  free  and  patent  opening  the 
expiratory  portion  of  the  amphoric  sound  is  peculiarly  dis- 
tinct. In  these  latter  cases  with  free  opening,  the  voice- 
sounds  may  be  attended  with  a  metallic  echo  quite  peculiar, 
whereas  in  the,  more  valvular  cases  the  voice-sounds  are  not 
conducted  at  all.  Metallic  tinkling  is  frequently  present,  and 
is  a  useful  additional  sign — one,  however,  which  may  at  times 
be  heard  very  clearly  over  large  pulmonary  cavities.  Feeble 
and  more  or  less  modified  breath-sounds  are  heard  at  the 
apex,  where  there  are  still  adhesions,  and  immediately  after 
the  occurrence  of  perforation,  friction  sounds  may  develop 
over  portions  of  lung  as  yet  in  contact  with  the  thoracic 
wall. 

3.  Displacement  of  the  Heart. — M.  Gaide"'  was  the  first  to 
describe  displacement  of  the  heart  as  an  important  sign  of 
pneumothorax.  It  is,  indeed,  a  constant  and,  save  in  excep- 
tional cases  in  which  the  base  of  the  opposite  lung  is  con- 
solidated, an  essential  sign  of  perforation  of  the  pleura,  and 
it  is  singular  that  it  should  have  escaped  the  notice  of  such 
acute  clinical  observers  as  Laennec  and  Louis,  Its  occur- 
rence simultaneously  with  that  of  the  perforation,  noticed  but 
not  explained  by  M.  Gaide,  is  a  fact  that  would  of  itself  cast 
suspicion  upon  the  usual  acceptance  of  the  sign  as  being  • 
necessarily  one  of  pressure.  The  cardiac  displacement  may 
be  observed  within  a  few  minutes  of  the  perforation,  and  is 
due,  in  the  first  instance,  to  the  sudden  removal  from  the 
mediastinum  of  the  elastic  traction  of  the  lung  which  has 
collapsed,  and  the  consequent  unopposed  traction  upon  it  of 
the  other  lung.  If  the  opposite  lung  be  not  soHdified,  the 
heart  may  from  this  cause  alone  be  carried  beyond  the  median 


PLATE  VI 


Radiogram  of  Chest  in  a  Case  of  Right-Sided  Pyo-Pxeumothorax 
(Taken  by  Dr.  Stanley  Melville.)  ^u^horax. 


To  face  p.  i^ 


PYO-PNEUMOTHORAX 

The  radiogram  shows  the  appearances  met  with  in  a  case  of  right- 
sided  pyo-pneumothorax,  the  radiogram  being  taken  with  the  patient 
in  the  standing  position. 

The  heart  and  mediastinum  are  drawn  somewhat  to  the  left,  and 
the  left  lung  shows  evidence  of  tuberculous  infiltration.  The  deep 
shadow  of  the  fluid,  with  horizontal  upper  limit,  is  well  seen  on 
the  nght  side,  together  with  the  bright  air-containing  space  above. 
The  right  lung  is  collapsed  along  the  vertebral  column,  except  at 
the  apex. 

From  a  man  aged  twenty-six.  who  suffered  from  pulmonary 
tuberculosis. 


PLATE  VI 


PNEUMOTHORAX  J  47 

line.  Thus,  we  have  recorded  two  cases,  and  have  seen 
several  others,  in  which  the  heart  was  displaced  to  the  right 
of  the  sternum,  yet  in  which,  as  proved  post-mortem  by  the 
manometer,  no  intrathoracic  pressure  existed.'^ 

On  a  screen  examination  by  the  X-rays  the  affected  side  is 
seen  to  be  brighter  or  more  transradiant  than  the  sound  side, 
owing  to  there  being  now  less  tissue  to  oppose  the  passage 
of  the  rays  (see  Plate  VI.).  The  shadow  of  the  collapsed 
lung  may  be  observed  by  the  side  of  the  vertebral  column, 
and  the  displacement  of  the  heart,  already  detected  by  physi- 
cal examination,  will  be  confirmed.  If  fluid  be  present  as 
well  as  air,  the  appearances  seen  are  striking.  In  the  erect 
posture  the  upper  portion  of  the  chest,  where  the  air  is  now 
collected,  will  show  the  increased  translucency  characteristic 
of  pneumothorax,  the  lower  portion  yielding  the  dark  shadow 
of  fluid.  The  line  of  demarcation  between  the  two  is  sharp 
and  clear.  Further,  the  level  of  the  fluid,  unlike  that  of  a 
simple  pleural  effusion,  is  absolutely  horizontal — a  water- 
level  in  any  position  which  the  patient  may  assume.  This 
fact,  when  observed,  is  of  great  importance,  and  proves  the 
presence  of  a  cavity  within  the  chest  containing  air  and 
fluid.  The  upper  level  of  the  fluid,  whether  serum  or  pus,  is 
rarely  still,  and  this  is  especially  the  case  if  the  disease  be 
left-sided,  the  surface  showing*  continual  rippling  movements 
conveyed  from  the  heart,  and  presenting  a  very  striking  pic- 
ture. On  shaking  the  patient,  the  fluid  is  seen  to  dash 
against  the  sides  of  the  pleural  cavity  and  to  rebound,  form- 
ing waves,  which  accurately  explain  the  mechanism  of  the 
succussion  splash. 

Course  and  Prognosis.— In  the  majority  of  instances  pneu- 
mothorax occurs  towards  the  close  of  the  disease,  when  the 
patient  is  already  dying  of  extensive  pulmonary  lesions.  It 
is  as  a  rule,  therefore,  of  grave  augury,  although  the 
practice  of  early  evacuating  the  air  from  the  distended  pleura 
has  considerably  diminished  the  immediate  danger  of  the 
complication.'^ 

Should  the  patient  survive  this  primary  danger,  the  heart 
and  circulation  gradually  become  accustomed  to  the  altered 
conditions,  and  in  the  most  favourable  cases  the  air,  after  a 
few  weeks,  becomes  absorbed,  the  lung  re-expands,  and 
the   heart   returns   to   its   normal   position.     Such   an   event 


148  DISEASES   OF  THE  LUNGS   AND  PLCURiE 

is  not  uncommon  when  pneumothorax  occurs  in  persons 
apparently  healthy,  or  in  whom  the  lesions  of  pulmonary 
tuberculosis  are  so  slight  as  to  give  no  physical  signs.  But 
in  cases  of  manifest  phthisis  such  recovery,  though  we  have 
known  instances  of  it,  is  rare.  Fluid,  usually  of  a  serous  or 
sero-purulent  nature,  generally  becomes  effused.  This  may 
after  some  weeks  be  reabsorbed,  the  air  at  the  same  time  dis- 
appearing. More  commonly  it  happens  that  the  fluid  remains, 
and  if  the  perforation  in  the  pleura  has  healed,  and  the  lung- 
is  unable  to  expand,  the  case  becomes  converted  into  one  of 
chronic  hydrothorax.  This  latter  termination  is,  however, 
exceptional.  As  a  rule,  when  a  hydro-pneumothorax  has  been 
established,  the  condition  remains  unchanged  for  months,  or 
even  in  exceptional  cases  for  years,*  until  the  patient  dies 
from  the  spread  of  the  primary  disease,  or  more  rarely  from 
the  sudden  onset  of  acute  foetid  pleurisy,  putrefactive  organ- 
isms having  found  access  to  the  pleura.  We  have  more  than 
once  met  with  cases  in  which  the  occurrence  of  pneumothorax 
has  seemed  to  arrest  the  activity  of  the  disease  in  the  lung 
affected,  and  to  prolong  life.  Of  fifty-eight  cases  of  pneumo- 
thorax collected  from  the  post-mortem  records  of  the  Bromp- 
ton  Hospital,  the  greatest  durations  of  life  were  twelve,  eight, 
seven,  five,  four  and  a  half,  and  four  months  in  six  cases 
respectively.  The  shortest  durations  were  ten  minutes,  fifteen 
minutes,  and  six  hours. 

We  have  been  speaking  so  far  of  the  prognosis  of  pneumo- 
thorax when  secondary  to  pulmonary  tuberculosis.  In  other 
conditions  the  outlook  must  vary  with  the  cause.  In  cases 
of  gangrene  of  the  lung,  the  rupture  of  septic  infarcts,  and 
bronchiectasis  the  result  is  almost  always  fatal,  partly  on 
account  of  the  primary  disease  and  partly  from  the  severe 
septic  inflammation  originated  in  the  pleura.  In  cases  of 
emphysema,  on  the  other  hand,  and  of  empyema  bursting  into 
the  lung,  the  prognosis  is  more  favourable,  provided  that  in 
the  latter  case  the  pus  is  freely  evacuated  by  surgical 
measures. 

Diagnosis.— There  is  as  a  rule  but  little  difficulty  in  dis- 
tinguishing a  case  of  pneumothorax,  in  which  the  effusion  of 

*  The  experience  of  Dr.  Morse,"  who  records  six  instances  of  recovery 
out  of  fourteen  cases  of  tuberculous  hydro-pneumothorax  with  serous 
effusion,  is  most  exceptional. 


PLATE  VII 


Radiogram  of  a  Case  of 

Pyo -Pneumothorax  Subphrenicus,  viewed  from  the  Front. 

(Taken  by  Dr.  Hugh  Walsham.) 


To  face  p.  149. 


JlasmoJa  n't  liA" 


_      ,      ,   ,  .'   bri.c^it    air-con tafii  11? 

'ndi 


:)SC 


-PNEUMOTH<>RA-; 


Si.  Bl'HKENi< 


35^neath- the  vlfiult  of  the  diaphragm,  on  its  right  ■■ 

^pa..e,     her.  ;■(.:•:•'!     i'cifew     )>\ 


jw,    along  .vvhidi,    on   shaking 

ating   the     ■•]-\>f'A    limit  vf  th,-   m., 

CSS  conta 


woberfS 
noiaufta  iBioalq  zuom  >o 

•qu    bsriaoq    mssidqaiO: 
ebiBW 


(Ufisnsd  ,i(iJvBD  9d)  ni  irA 
gainifiinoo   ,ni:gci({q6ib 
2uq  biic  (is 

f^^  I$SfsJi;!^sqqo  IsJnosboH 
DittsdqaBe  3ff|  riiaoqsrtt 


f   )      I  nir      ■..■■  t  M".-  J       .1; I  j\j      I  ' ; c-      ; V,  I  • 


ber.i 


afh  the  diaphvagm  the  stoma; 


■om  a  man  aged  forty,  who  suffered  from  a  subphrenic  abscess 
asscciated  with  intrahepatic  suppuration. 


PLATE  VII 


PNEUMOTHORAX  1 49 

air  is  extensive,  from  any  otker  morbid  state.  Emphysema  is 
the  only  other  affection  in  which  we  obtain  hyper-resonance 
and  enfeebled  breathing  combined.  But  in  emphysema  the 
disease  affects  both  hmgs,  the  note  lacks  the  drum-like  quality 
found  in  pneumothorax,  the  respiration  is  never  quite  sup- 
pressed, it  is  not  amphoric  in  quality,  and  the  heart  is  not 
laterally  displaced. 

It  is  sometimes  very  difficult  to  distinguish  between  a  local- 
ised pneumothorax  and  a  large  thin-walled  pubnonary  cavity. 
Such  cavities  may  yield  almost  tympanitic  resonance  and 
metallic  tinkling,  whilst  the  bell  sound,  movable  dulness,  and 
succussion  splash  may  all,  though  rarely,  be  elicited,  as  in 
a  case  which  we  have  recorded.^"  But  localised  pneumo- 
thorax is  most  commonly  situated  at  the  lower  portion  of  the 
thorax,  and  in  this  situation  such  a  largS  pulmonary  cavity 
as  could  be  confounded  with  it  is  of  most  rare  occurrence, 
unless  it  be  continuous  from  the  apex  downwards,  in  which 
case  the  heart's  beat  would  be  felt  on  the  affected  side. 
Except  for  the  position  of  the  heart,  the  X-ray  appearances 
of  total  excavation  of  the  lung  may  exactly  resemble  those 
of  a  hydro-  or  pyo-pneumothorax.-' 

Occasionally  a  diaphragmatic  hernia,  with  escape  of 
stomach  and  colon  into  the  left  side  of  the  chest,  and  with 
displacement  of  heart  to  the  right,  may  simulate  a  pneumo- 
thorax. But  here  a  bismuth  meal  and  X-ray  examination  will 
reveal  the  true  nature  of  the  case. 

Another  source  of  error  is  the  occurrence  of  an  abscess 
beneath  the  diaphragm  containing  both  air  and  fluid,  a  con- 
dition originally  described  by  Leyden-  under  the  name  pyo- 
pneumothorax subphrenicus.  This  is  most  often  secondary 
to  perforation  of  a  gastric  or  duodenal  ulcer.  The  abdominal 
symptoms  in  the  preceding  history  of  the  case,  the  absence  of 
cough,  expectoration,  and  of  pulmonary  signs  in  the  upper 
portions  of  the  chest,  together  with  the  comparatively  slight 
cardiac  displacement,  are  points  which  should  help  to  direct 
diagnosis  aright.  An  X-ray  examination,  provided  the 
patient's  condition  permit,  gives  valuable  confirmatory  evi- 
dence, revealing  the  fixed  condition  and  upward  displacement 
of  the  diaphragm,  and  beneath  it  the  presence  of  a  cavity 
containing  air  and  fluid  (see  Plate  VII.). 

But  the  cases  which  we  have  seen  most  often  mistaken  for 


150  DISEASES   OF  THE  LUNGS   AND  PLEURA 

pneumothorax  have  been  those  of  advanced  phthisis,  in  which 
acute  congestion  has  rapidly  supervened  at  the  base  of  the 
comparatively  sound  lung.  Pain  limits  the  movements  and 
lessens  the  sounds  over  the  newly  affected  part;  there  is  con- 
siderable high-pitched  resonance  on  percussion;  and  the 
symptoms,  setting  in  suddenly  and  acutely,  may  be  precisely 
those  of  pneumothorax.  But  on  careful  auscultation  breath- 
sound  and  rhonchus  can  be  heard;  the  heart  is  not  displaced, 
nor  is  the  percussion  note  truly  tympanitic. 

Sometimes,  also,  at  first  sight  the  dyspnoea  of  asthma 
resembles  that  of  pneumothorax,  and  with  general  hyper- 
resonance  we  may  have  in  asthma  an  absence  of  respiration 
over  portions  of  the  chest.  But  the  portions  of  lung  so 
affected  will  vary  in  position,  perhaps,  even  whilst  we  are 
listening,  and  the  general  wheezing  rales  elsewhere  present, 
together  with  the  history  of  the  case  and  the  effect  of  treat- 
ment, will  prevent  any  real  difficulty  in  diagnosis.  Again,  we 
have  seen  more  than  one  case  of  hysterical  dyspnoea  suggest- 
ing pneumothorax,  but  the  expression  of  countenance  cannot 
be  simulated,  and  a  moderately  careful  physical  examination 
will  lead  to  a  right  conclusion. 

The  diagnosis  of  pyo-pneumothorax  from  simple  empyema 
is  not  difficult,  the  succussion  splash  and  the  marked  shifting 
of  the  dulness  and  resonance  with  change  of  posture,  as  well 
as  the  X-ray  appearances,  being  quite  characteristic  of  the 
former.  Nevertheless,  we  must  remember  that  certain  cases 
of  apparently  pure  empyema  have  their  origin  in  perforation 
of  the  lung,  the  rupture  having  closed  and  the  air  undergone 
complete  absorption. 

But  the  diagnosis  in  pneumothorax  does  not  consist  merely 
in  separating  it  from  other  diseases,  but  also  in  distinguishing 
the  kind  of  perforation  that  has  taken  place  and  the  probable 
existence  or  not  of  air-pressure  within  the  thorax.  The  dis- 
covery of  amphoric  (to-and-fro)  breathing  strongly  suggests 
that  the  opening  is  a  free  one,  admitting  the  ready  passage  of 
air  both  ways,  and  that,  consequently,  no  air-pressure  is 
present.  On  the  other  hand,  the  complete  absence  of  all 
breath-sounds,  with  increasingly  urgent  dyspnoea,  distended 
side,  and  greatly  displaced  and  oppressed  heart,  are  equally 
significant  of  a  valvular  opening  and  of  increasing  intra- 
thoracic pressure. 


PNEUMOTHORAX  151 

Treatment. — Life  is  threatened  on  the  occurrence  of  pneu- 
mothorax hy  shock,  asphyxia,  and  exhaustion,  and  these  are 
the  special  indications  for  treatment.  The  shock,  which  is 
-due  to  the  sudden  lesion  of  a  vital  organ  and  to  the  sudden 
dislocation  and  impeded  action  of  the  heart,  must  be  treated 
by  the  administration  of  a  stimulant,  but  above  all  things  by 
an  opiate.  Opium  is  most  valuable  in  calming  the  nervous 
system  and  in  lessening  the  sense  of  dyspnoea.  A  dose  of 
morphia  may  be  given  subcutaneously,  and  the  treatment  con- 
tinued in  the  form-  of  a  pill  of  opium  with  camphor.  Increas- 
ing pressure  within  the  chest,  if  present,  must  be  treated  by 
the  timely  introduction  of  a  fine  trocar.  For  this  purpose  a 
Southey's  trocar  with  fine  rubber  tube  attached  may  be 
employed.  The  tube  should  open  below  into  boracic  lotion  to 
prevent  the  entry  of  air  into  the  chest  during  inspiration,  but 
in  emergency  any  fine  instrument  may  be  used.  This  trifling 
operation  gives  great  and,  curiously,  sometimes  lasting  relief. 
If  necessary,  it  may  be  repeated.  After  the  excess  of  air  has 
been  removed,  the  side  may  be  strapped  so  as  to  control 
inspiratory  movement.  A  broad  band  of  strapping  firmly 
applied  over  the  lower  ribs,  and  reaching  some  two  or  three 
inches  beyond  the  middle  line  in  front  and  behind,  is  sufficient 
to  attain  this  end.  Positive  pressure  is  brought  about  within 
the  pleura  by  the  thoracic  wall  on  the  affected  side  becoming 
expanded  to  the  position  of  extreme  inspiration,  and  then 
recoiling  upon  the  air  pent  up  in  the  pleura.  By  diminishing 
the  inspiratory  movements  we  may  hope  to  prevent  this  ex- 
cessive accumulation  of  air,  with  all  its  attendant  conse- 
quences. 

As  a  rule  pneumothorax  occurs  in  persons  already  reduced 
in  flesh  and  blood  by  previous  illness.  If  the  accident  should 
occur  at  an  earlier  period  of  the  disease,  the  venous  engorge- 
ment, lividity,  and  general  circulatory  distress  resulting  from 
the  embarrassment  and  dilatation  of  the  right  side  of  the 
heart,  will  be  correspondingly  marked.  In  such  cases  free  dry- 
cupping  will  give  great  relief.  The  portal  system  being  the 
great  reservoir  for  retarded  blood,  an  occasional  saline 
aperient  is  of  value  in  pneumothorax,  and  also  serves  to 
correct  the  constipating  effects  of  opium,  the  administration 
of  which  in  repeated  small  doses  is  on  other  grounds  desirable 
for. the  first. few  days. 


152  DISEASES   OF  THE  LUNGS   AND   PLEURiE 

When  effusion  has  occurred,  we  must  not  be  in  too  great  a 
hurry  to  withdraw  it,  provided  it  be  of  the  usual  serous  or 
sero-purulent  variety,  since  a  certain  delay  will  assist  in  clos- 
ing the  rupture  in  the  pleural  membrane.  But  should 
pressure  symptoms  ensue,  we  may  remove  a  portion,  care 
being  taken  not  to  produce  a  negative  pressure  in  the  pleura, 
lest  the  rupture  recently  healed  be  reopened.  The  syphon 
may,  therefore,  be  employed,  or,  if  the  aspirator  be  used,  the 
fluid  must  be  allowed  to  flow  with  as  little  suction  as  possible. 

If  the  fluid  returns,  a  second  paracentesis  may  be  performed ; 
but,  should  this  also  fail,  it  is  better  as  a  rule  to  suspend 
active  treatment.  The  patient  suffers  little,  and,  provided  the 
disease  in  the  other  lung  be  fairly  quiescent,  he  may  live  for 
many  months,  or  occasionally  for  some  years,  in  that  con- 
dition, dying  at  length  from  the  spread  of  tubercle  in  the 
opposite  lung,  or  from  the  invasion  of  the  larynx  and  more 
distant  parts. 

Should  the  patient,  however,  complain  of  the  weight  in  the 
chest  caused  by  the  effused  fluid,  relief  may  be  given,  and 
possibly  some  expansion  of  the  lung  effected,  by  paracentesis 
followed  by  oxygen  replacement,-^  as  described  when  speak- 
ing of  cases  of  chronic  pleurisy  (see  p.  114).  But  we  must  re- 
member that  in  cases  of  pneumothorax  any  traction  exerted 
upon  the  lung  must  be  gentle  lest  the  perforation  which 
has  now  closed  should  reopen,  with  the  attendant  danger  of 
septic  infection. 

In  a  case  of  pyo-pneunvothorax  when  the  fluid  is  distinctly 
purulent  and  contains  pyogenic  micro-organisms,  and  pyrexia 
is  present,  paracentesis  should  be  performed  and  repeated  if 
necessary,  but  if  the  patient  continues  to  lose  ground,  incision 
and  evacuation  of  the  pus,  with  subsequent  drainage,  is  our 
only  course,  provided  the  general  condition  does  not  forbid. 
In  certain  cases  thus  treated  the  perforation  in  the  pleura  has 
closed,  and  the  lung  has  re-expanded,  though  a  fistula  may  per- 
sist.^' Should  the  expansion  of  the  organ  be  incomplete,  and 
the  chest  not  fall  in  sufficiently,  later  on  a  modified  Estlander's 
operation  may  be  required.  We  have  known  a  remarkable 
case  in  which  this  was  successfully  performed.  Each  case 
must,  however,  be  separately  considered,  and  treated  on 
its  own  merits.  If  there  is  little  or  no  fever,  and  the  patient's 
condition  be  satisfactory,  it  will  be  wiser  to  leave  well  alonc> 


PNEUMOTHORAX  1 53 

to  perform  paracentesis  from  time  to  time  when  required,  but 
not  to  proceed  to  more  drastic  surg-ical  measures.  How  long 
cases  of  pyo-pneumothorax  not  operated  upon  may  continue 
to  live  is  well  exemplified  by  the  history  of  the  following 
patient : 

Mr.  T.,  aged  twenty-nine,  was  first  seen  in  1902.  His  father  had 
suffered  from  "  weak  lungs,"  and  died  early,  but  the  family  history 
was  otherwise  satisfactory.  He  was  delicate  as  a  child,  but  became 
robust  at  sixteen,  and  excelled  at  sports,  being  accustomed  to  con- 
tend in  fift3'-mile  bicycle  races  with  success.  In  1895  he  was  passed 
as  medically  sound  for  the  public  service,  but  for  family  reasons  he 
entered  upon  a  commercial  career  in  London.  In  1897  he  married, 
and  four  children  were  born,  one  of  whom  died  at  birth,  and  one  of 
tuberculous  meningitis  at  fifteen  months. 

In  1901  he  contracted  repeated  "  colds,"  and  in  December  of  that 
year  he  developed  early  tuberculous  trouble  at  the  left  apex,  with 
tubercle  bacilli  in  the  sputum,  and,  by  the  advice  of  his  family 
physician  and  a  consultant,  went  to  Torquay,  where  he  improved 
considerably  for  a  time. 

On  May  9,  1902,  he  was  sent  to  Sir  R.  Douglas  Powell  by  Dr. 
Edwin  Smith,  of  Tooting.  Consolidation  of  the  upper  third  of  the 
left  lung  was  found,  but  the  constitutional  symptoms  were  mainly 
in  abeyance.  The  alternatives  of  his  remaining  in  town  with  pre- 
cautions and  of  his  taking  a  voyage  were  considered  and  negatived, 
and  treatment  at  a  sanatorium  for  at  least  three  or  four  months 
was  strongly  advocated,  with  a  hopeful  prognosis.  Some  creosote  was 
prescribed. 

In  September  of  that  year  he  returned  from  a  four-months  course 
of  treatment  at  a  Hampshire  sanatorium,  having  gained  i  stone  in 
weight  (9  stone  2  pounds),  with  a  normal  temperature  and  only 
slight  morning  cough.  He  could  walk  ten  or  fourteen  miles  a  day. 
Although  the  physical  signs  at  the  left  apex  remained,  with  some 
coarse  crackles,  the  right  lung  had  expanded  across  the  sternum. 
He  went  to  Bournemouth,  where  he  bought  a  house,  and  remained 
with  his  wife  and  family.  In  January,  1903,  his  weight  was  9  stone 
6  pounds,  the  disease  quiescent,  with  some  fibroid  changes.  Tempera- 
ture normal. 

In  June,  1904,  he  reported  that  he  had  early  in  the  year  had 
some  relapse  of  symptoms.  His  child  had  died  from  tuberculous 
meningitis,  and  he  had  suffered  from  pleurisy,  with  loss  of  weight. 
For  the  last  six  months,  however,  his  temperature  had  been  normal, 
and  his  present  weight  was  9  stone  4  pounds. 

In  May,  1905,  he  developed  pneumothorax  on  the  left  side  below 
the  fifth  rib  in  front  and  behind,  followed  later  by  fluid  effusion.  He 
was  exceedingly  ill  for  some  time,  and  at  the  end  of  four  months 
was  only  just  able  to  stand.  He  then  again  improved  rapidly,  and 
after  nine  months  reported  himself  as  better  than  before  the  pneumo- 


154  DISEASES   OF  THE  LUNGS   AND   PLEUR.E 

thorax.  His  -cough  had  disappeared,  he  had  gained  weight,  and  the 
temperature  was  normal.  The  signs  of  pneumothorax,  howeyer, 
persisted.  His  letter,  written  on  July  9,  1906,  contains  the  fol- 
lowing interesting  passage  :  "  Of  the  thirteen  patients  of  a  group 
taken  when  I  was  at  the  sanatorium  (in  1902),  nine  are  dead.  Of  the 
remaining  four  I  am  one;  of  two  I  am  doubtful,  and  one  is  really 
soundly  cured,  and  he  is  the  careless  one  who  plays  hockey  in  Ire- 
land. ...  I  have  just  noticed  we  were  thirteen  !  .  .  .  I  have  been 
through  more  than  any  of  those  who  died,  but  I  think  it  has  much 
to  do  with  will-power,  and  not  allowing  oneself  to  worry."  In  regard 
to  this  psychical  aspect  of  the  matter,  Mr.  T.  deprecates  the  practice 
of  enjoining  patients  to  take  their  temperature  three  times  a  day, 
adding:  "When  it  is  up,  they  worry  until  it  goes  higher.  I  went 
to  105-2°,  but  I  did  not  mind.  A  sensitive  girl  would  have  died  of 
fright.  I  am  a  layman,  I  know,  but  I  feel  that  mind  is  half  the 
battle  one  way  or  another." 

In  June,  1907,  Mr.  T.  was  seen  again  in  consultation  with  Dr. 
Hyla  Greves,  and  he  was  found  still  to  present  all  the  physical 
signs  of  pyo-pneumothorax,  communicating  with  and  discharging 
through  the  lung.  The  question  of  opening  up  the  pleura,  with 
removal  of  some  of  the  ribs,  with  the  hope  of  closing  the  cavity, 
was  carefully  considered,  and  was  reluctantly  abandoned  as 
a  measure  that  would  probably  have  had  an  immediately  fatal 
result.  He  was  advised  to  evacuate  the  pleural  cavity  as  far  as 
possible  by  natural  means  and  at  stated  intervals.  With  his  usual 
determination  he  set  to  work  to  carry  out  directions  by  a  process 
of  "  tilting-up,"  as  he  expresses  it,  "  lying  on  a  lounge-chair  with  head 
on  the  floor  and  legs  up  the  back  of  the  chair,"  thus  inducing  cough 
and  expectoration. 

In  February,  1909,  Mr.  T.  wrote  that  since  June,  1907,  he  had 
"  tilted  up  "  twice  and  later  three  times  a  week,  and  had  brought  up 
altogether  about  lo-l  gallons  of  pus,  carefully  measured,  but  that  at  the 
date  of  writing  he  expectorated  only  about  -|  pint  each  time.  Recently 
there  had  been  intervals  of  perhaps  a  week  without  expectoration, 
"  the  safety-valve  having  struck  work,"  as  he  describes  it,  during 
which  time  he  became  "  depressed,  weak,  and  austere.  The  block 
then  gives  way,  and  at  the  next  attempt  at  evacuation  there  is  a 
sudden  rush,  and  i^  pints  of  pus  may  be  brought  up."  In  a  later 
letter,  in  May,  19 10,  he  states  that  he  is  much  better,  expectorating 
only  about  an  eggcupful  every  day,  though  the  total  amount 
evacuated  by  the  tilting  process  had  now  reached  15  gallons.  On 
October  25,  1910,  Dr.  Hyla  Greves  writes  :  "  At  the  present  time 
Mr.  T. 's  condition  is  very  fairly  good,  considering  all  he  has  gone 
through.  The  left  side  of  the  chest  has  fallen  in  greatly,  and  the 
pneumothorax  cavity  correspondingly  diminished  in  size,  the  amount 
of  expectoration  discharged  by  '  tilting  up  '  being  comparatively  small. 
The  right  lung  shows  very  few  indications  of  disease,  but  there  are 
a  few  moist  sounds  in  the  upper  lobe.     Some  months  ago  he  had  a 


PNEUMOTHORAX  1 55 

good  deal  of  abdominal  pain  and  discomfort,  and  I  feared  the  possi- 
bility of  tuberculous  disease  of  his  intestines,  but  careful  dieting  and 
having  his  teeth  put  into  proper  order  has  apparently  got  rid  of  this 
condition.  He  is  able  to  take  a  moderate  amount  of  walking  exercise 
daily." 

The  patient  continued  under  Dr.  Greve's  skilful  and  inspiriting 
care  and  kept  fairly  well,  but  the  disease  in  the  right  lung  made 
progress,  and  signs  of  a  cavity  developed  in  the  upper  lobe.  On 
April  22,  1912,  Mr.  T.  had  his  first  attack  of  haemoptysis,  the  blood 
probably  coming  from  the  right  lung.  The  haemorrhage  recurred  on 
several  occasions  and  greatly  reduced  his  strength.  He  died  in 
June,  1912. 

This  case  is  in  some  respects  a  remarkable  one  of  endurance 
and  will-powder  in  contending  against  a  disease  which  would 
certainly  have  sooner  proved  fatal  in  a  less  sanguine  and 
determined  man,  and  on  this  account  appears  worthy  of 
record.  The  death-rate  incidentally  mentioned  amongst  his 
sanatorium  contemporaries  is  interesting. 

REFERENCES. 

'  "  Dissertation  sur  le  Pneumothorax,  ou  les  Congestions  Gazeuses  que 
se  forment  dans  la  Poitrine,"  par  M.  Itard,  Presentee  et  Soutenue  a  VEcole 
de  Mcdecine  de  Paris.  Paris,  1803.  (Quoted  by  Laennec.  We  have  been 
unable  to  obtain  a  copy  of  the  original  essay.) 

*  Train  de  f  Auscultation  Mediate  et  des  Maladies  des  Pouvions  et  du 
Caur,  par  R.  T.  H.  Laennec,  troisieme  edition,  tome  ii.,  p.  414.  Paris, 
1831. 

^  "  Zur  CEtiologie  des  Pneumothorax,"  von  Dr.  Alois  Biach,  in  Wien, 
Wiener  Medizinische  Wochenschrift,  1880,  p.  6,  etc. 

*  See  the  Bradshawe  Lecture  on  "  Pneumothorax,"  by  Samuel  West, 
'M.D.,  Lancet,  1887,  vol.  ii.,  p.  353. 

^  The  Diseases  of  the  Lungs,  by  James  Kingston  Fowler,  M.D.,  F.R.C.P., 
and  Rickman  John  Godlee,  M.S.,  F.R.C.S.,  p.  627.     London,  1898. 

"  "Pneumothorax  without  Urgent  Symptoms,  followed  by  Recovery; 
subsequent  Death  of  the  Patient  from  Dissecting  Aneurism  of  the  Aorta," 
by  W.  H.  Ranking,  M.D.,  F.R.C.P.,  British  Medical  Journal,  August  25, 
i860,  p.  665. 

'  See  papers  on  this  subject  by  Dr.  Douglas  Powell  in  The  Medical 
Times  and  Gazette  for  January  and  February,  1869. 

*  Abstracted  from  the  annual  "  Reports  of  the  Post-Mortem  Examina- 
tions "  made  at  the  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton. 

'  [a)  Re-port  on  the  Work  of  the  Pathological  De-part7nent  of  the  Br  om  ft  on 
Hospital  during  the  Three  Years  1900  to  1903,  by  P.  Horton-Smith 
(Hartley),  M.D.,  p.  12.     London,  1903. 
{b)  Loc.  cit.,  p.  25. 
"  See  Fourth  Edition  of  this  work,  London,  1893,  p.  155. 
"  "  A   Contribution   to   the   Pathology   of   Pneumothorax,"   by    Samuel 
West,  M.D.„  Lancet,  1884,  vol.  i.,  p.  791. 


156  DISEASES   OF  THE  LUNGS   AND  PLEURA 

"  "On  Some  Effects  of  Lung  Elasticity  in  Health  and  Disease,"  by 
R.  Douglas  Powell,  M.D.,  Transactio7is  of  the  Royal  Medical  and  Chir- 
urgical  Society,  1876,  vol.  lix.,  p.  179. 

"  "  Observations  on  Air  found  in  the  Pleura  in  a  Case  of  Pneumothorax, 
with  Experiments  on  the  Absorption  of  Different  Kinds  of  Air  introduced 
into  the  Pleura,"  by  John  Davy,  M.D.,  F.R.S.,  Philosophical  Transactions 
of  the  Royal  Society  of  London,  1823,  p.  496,  and  1824,  p.  257. 

"  (i)  "  Untersuchungen  zur  Gasometrie  der  Transsudate  des  Menschen," 
von    Dr.     C.     Anton     Ewald,     zu     Berlin,     Archiv    fiir    Anatomic, 
Physiologic,  und  Wissenschaftliche  Medicin  (Reichert  und  Du  Bois- 
Re3'mond),  p.  422.     Leipzig,  1876. 
(2)  "  Ueber    ein    leichtes    Verfahren,    den    Gasgehalt    der    Luft    eines 
Pneumothorax  und  damit  das  Verhalten  der  Perforations-offnung  zu 
bestimmen,"  von  Dr.   C.  A.   Ewald,   Charite-Annalen,  ii.  Jahrgang, 
1875,  p.  167.     Berlin,  1877. 
"  "  Contributions  to  Morbid  Anatomy,"    No.  iv.,  by  Andrew  Duncan, 
jun.,     M.D.,     The     Edinburgh     Medical     and    Surgical    Journal,     1827, 
vol.   xxviii.,   p.   302. 

"  "  Observations  Cliniques  Recueillies  a  I'Hopital  Saint-Antoine,"  par 
M.  A.  Gaide;  "Observations  de  Pneumothorax,"  Archives  Generales  de 
Medecine,  tome  xvii.,  p.  345.     Paris,   1828. 

"  "  Cases  illustrating  the  Manner  in  which  the  Heart  is  displaced  in 
Pneumothorax,"  by  R.  Douglas  Powell,  M.D.,  The  Medical  Times  and 
Gazette,  August  21,  1869,  p.  218. 

'*  How  rapidly  fatal  pneumothorax  usually  proved  before  the  intro- 
duction of  paracentesis  and  the  evacuation  of  the  air  is  indicated  in  the 
following  paper,  "  The  Prognosis  of  Pneumothorax,  with  Some  Statistics 
as  to  the  Mortality  and  Duration,  and  an  Account  of  a  Series  of  Cases  of 
Recovery,"  by  Samuel  West,  M.D.,  Transactions  of  the  Medical  Society 
of  London,  1897,  vol.  xx.,  p.  103. 

"  "  An  Analysis  of  Fifty-one  Cases  of  Pneumothorax,"  by  John  Lovett 
Morse,  A.M.,  M.D.  (Boston),  The  American  Journal  of  the  Medical 
Sciences,  May,  1900,  p.  503. 

^^  "A  Case  of  Pulmonary  Tuberculosis  with  extensive  Excavation  simu- 
lating a  Pyo-pneumothorax,"  by  P.   Horton-Smith  Hartley,  St.   Bartholo- 
meiv^s  Hospital  Reports,  vol.  1.,  1914,  p.  121. 
^^  [a)  "  A  Case  of  Phthisis  with  complete  Cavitation  of  the  Left  Lung," 
by  D.   W.    Carmatt   Jones,   M.D.,   M.R.C.P.,   and  E.    S.   Worrall, 
M.R.C.S.,  L.R.C.P.,  The  Lancet,  1913,  vol.  i.,  p.  1445. 
[b)  Dr.  V^oxxs\\,Proceedings  of  the  Royal  Society  of  Medicine,  Electro- 
therapeutical  Section,  April,  1913,  vol.  vi.,  p.  113. 
^^  "  Ueber     Pyopneumothorax    subphrenicus     (und    subphrenische    Ab- 
scesse),"  von  E.  Leyden,  Zeitschrift  fUr  Klinische  Medicin,   1880,  vol.  i., 
p.  320. 

^^  "  Surgery  of  the  Lung  and  Pleura,"  by  H.  Morriston  Davies,  M.A., 
M.D.,  M.C.,  F.R.C.S.,  pp.  62,  46.     London,   1919. 
=t   See  (i)  The  Surgery  of  the  Chest,  by  Stephen  Paget,  M.A.,  F.R.C.S., 
p.  323.     Bristol  and  London,  1896. 
(2)  Diseases  of  the  Organs  of  Respiration,  by  Samuel  West,  M.D., 
F.R.C.P.,  vol.  ii.,  p.  S60.     London,  1909. 


CHAPTER  X 

HEMOTHORAX— GUNSHOT  WOUNDS  OF  THE  CHEST 

By  the  term  Hsemothorax  is  meant  the  effusion  of  pure  blood 
into  the  pleural  cavity,  the  condition  being  distinguished  from 
haemorrhagic  pleurisy,  in  which  the  inflammatory  exudation 
is  merely  tinged  with  blood. 

Haemothorax  may  be  secondary  to  disease,  or  result  from 
injury,  such  as  fractured  ribs,  but  is  most  commonly  a  sequel 
of  gunshot  wounds  of  the  thorax,  and  as  such  has  been  of 
frequent  occurrence  during  the  recent  war. 

The  amount  of  blood  poured  out  varies  from  a  few  ounces 
to  several  pints,  according  to  the  extent  of  the  wound  and  the 
source  of  the  haemorrhage,  whether  coming  from  lung,  aorta, 
intercostal  or  internal  mammary  artery. 

As  Colonel  Elhott  and  Major  Henry*  have  shown,  the  blood 
rapidly  clots,  but,  owing  to  the  cardiac  and  respiratory  move- 
ments, the  clot  is  not,  as  a  rule,  massive,  and  the  fibrin  is 
deposited  as  a  layer  upon  the  pleural  surfaces.  If  the  flviid  be 
removed  from  the  chest  and  tested  for  fibrinogen  none  will 
be  found,  showing  that  clotting  has,  in  fact,  occurred,  and 
that  the  fluid  is  really  defibrinated  blood.  As  a  result  of  the 
irritating  action  of  the  blood  a  low  degree  of  pleurisy  follows, 
and  serous  fluid  is  poured  forth,  mixing  with  and  diluting  the 
haemothorax. 

Haemothorax  in  Civil  Life. 

In  civil  life  haemothorax  is  not  common,  and  is  then  perhaps 
most  often  the  result  of  fracture  of  rib  with  lacerated  pleura. 
Another  cause  is  the  rupture  or  leakage  of  an  aortic  aneurism 
into  the  pleural  cavity.  Ulcerative  erosion  penetrating  the 
aorta,  intrathoracic  veins,  or  intercostal  arteries  has  also  been 
described  as  a  rare  precursor  of  this  condition  (Watson).     In 

157 


158  DISEASES   OF  THE  LUNGS   AND  PLEURA 

malignant  or  tuberculous  disease  haemorrhagic  pleurisy,  as  we 
have  already  seen,  is  not  uncommon;  but  definite  haemor- 
rhage into  the  pleura  is  rare.  In  scurvy,  purpura,  and  the 
malignant  forms  of  the  specific  fevers,  the  fluid  effused  into 
the  pleura  may  be  somewhat  blood-stained,  but  here  also  a 
true  hsemothorax  is  exceptional. 

It  sometimes  happens  that  with  the  blood  air  makes  its  way 
into  the  pleural  cavity,  and  a  Immopncumothorax  results,  an 
uncommon  condition  in  civil  practice,  of  which  but  few  cases 
are  recorded.  In  an  interesting  paper  Dr.  Newton  Pitt' 
described  a  case  due  to  the  rupture  of  an  emphysematous 
bulla,  and  referred  to  three  other  cases  from  the  post-mortem 
records  of  Guy's  Hospital.  In  two  of  the  latter  the  condition 
resulted  from  a  laceration  of  the  lung  (without  fracture  of  the 
ribs)  following  a  crush,  and  in  the  third  from  the  rupture  of  a 
phthisical  cavity  through  the  pleura,  this  event  being  followed 
shortly  afterwards  by  haemorrhage  from  an  ulcerated  vessel 
in  the  cavity  wall,  leading  both  to  haemoptysis  and  to  the  effu- 
sion of  blood  within  the  pleura. 

Symptoms. — The  symptoms  of  haemothorax  unassociated 
with  wounds  do  not  differ  materially  from  those  of  other 
pleuritic  effusions,  unless  the  haemorrhage  be  profuse,  in 
which  case  restlessness  and  distress,  a  rapid  and  irregular 
pulse,  and  other  signs  of  internal  haemorrhage  are  superadded. 
The  physical  signs  are  indistinguishable  from  those  of  other 
exudations  into  the  pleura,  and  except  when  caused  by  injury, 
the  condition  is  rarely  suspected  until  exploratory  puncture 
reveals  its  nature.  The  rapidity  with  which  the  fluid  collects 
might  in  some  cases,  however,  suggest  a  suspicion  as  to  the 
true  state  of  affairs. 

Treatment. — If  the  haemothorax  result  from  the  leaking  of 
an  aortic  aneurism,  clearly  we  should  not  interfere  unless  great 
displacement  of  heart  and  increasing  dyspnoea  render  para- 
centesis imperative,  since  the  pressure  of  the  effusion  will  tend 
to  check  the  further  flow  of  blood.  In  other  cases,  if  the 
effusion  be  large,  paracentesis  may  be  employed,  earlier 
recovery  having  been  observed  during  the  war  from  the  with- 
drawal of  the  fluid.  Each  case  must  be  judged  upon  its  merits, 
it  being  borne  in  mind  that,  if  the  primary  disease  permit 
recovery,  the  blood  will  be  gradually  absorbed  by  natural 
mearks,  though  this  process  may  be  slow.     Should  signs  of 


HEMOTHORAX  1 59 

suppurative  pleurisy  supervene  from  infection  of  the  pleura, 
surgical  treatment  must  not  be  delayed. 

Hsemothorax  following  Chest  Wounds. 

As  we  have  stated,  hsemothorax  has  been  of  frequent 
occurrence  during  the  war,  and  it  may  be  said  to  be  the 
common  sequel  of  a  gunshot  wound  of  the  chest.  In  such 
cases  the  blood  comes,  as  a  rule,  from  the  injured  lung,  more 
rarely  from  a  damaged  intercostal  or  internal  mammary  artery. 
It  is  not  uncommon  for  a  small  quantity  of  air  to  be  present  also 
in  the  pleura  during  the  early  stages,  and  for  the  case  to  be 
strictly  a  haemopneumothorax,  but  the  quantity  of  air  is  rarely 
large,  and  it  is  in  most  cases  rapidly  absorbed. 

Symptoms  and  Physical  Signs. — A  certain  degree  of  shock 
always  follows  a  wound  of  the  chest.  In  grave  cases  it  is 
severe,  and  it  is  estimated  that,  taking  all  chest  wounds 
together,  an  early  mortality  of  from  lo  to  15  per  cent,  results 
from  shock  and  primary  haemorrhage.'^  In  large  open  wounds 
exposing  the  pleural  cavity,  so  that  air  is  sucked  in  at  each 
inspiration,  so  called  Traumatopnoea,  shock  and  respiratory 
distress  prove  fatal  unless  relieved  by  surgical  treatment; 
but  in  simple  through-and-through  wounds  of  the  chest,  or 
those  in  which  a  small  missile  is  retained,  these  symptoms 
soon  abate,  and  the  case  becomes  one  of  hsemothorax,  though 
we  must  add  that  an  effusion  of  blood  into  the  pleural  cavity 
does  not  necessarily  occur  in  all  such  cases.  Haemoptysis  is 
of  frequent  occurrence,  and  may  recur  for  several  days,  but 
unless  it  arises  from  damage  to  a  larg'e  vessel,  when  it  may 
be  rapidly  fatal,  it  is  rarely  troublesome. 

The  physical  signs  of  haemothorax  resulting  from  a  pene- 
trating- wound  of  the  chest  are  sometimes  those  of  pleural 
effusion — namely,  impaired  note,  diminished  vocal  fremitus, 
breath-sounds  and  voice-sounds,  with  displacement  of  heart 
towards  the  sound  side,  and  if  the  effusion  be  of  sufficient 
extent,  enlargement  of  the  affected  side.  As  Sir  John  Rose 
Bradford^  has,  however,  pointed  out,  in  many  cases  the  signs 
are  different,  and  the  affected  side,  though  dull  over  the  effu- 
sion, is  retracted  and  almost  motionless,  and  the  diaphragm 
elevated.  Bronchial  and  even  cavernous  breath-sounds  with 
bronchophony  and  aegophony  are  heard  over  the  area  of 
fluid,  and  above  this  level,  marked  skodaic  resonance.     These 


l6o  DISEASES   OF  THE  LUNGS   AND   PLEURA 

signs  have  often  led  to  the  mistaken  diagnosis  of  traumatic 
pneumonia,  but  the  heart's  apex-beat,  be  it  noted,  is  usually 
displaced  towards  the  healthy  side.  It  would  appear  that 
these  peculiar  signs  are  the  result  of  an  underlying  massive 
collapse  of  the  lung,  ■*  """^  ^°  a  condition  which  will  be  dis- 
cussed more  fully  in  Chapter  XX. 

Course. — The  blood  poured  out  in  a  case  of  gunshot  wound 
of  the  chest  rapidly  reaches  its  maximum,  owing  partly  to  the 
collapse  of  the  lung,  which  checks  the  outflow,  and  partly  to 
the  deposition  of  fibrin,  which  soon  occurs,  and  which  tends, 
by  forming"  adhesions,  to  circumscribe  the  effusion.  There  is 
still  some  dyspnoea  on  recovering  from  shock,  but  it  is  not 
urgent,  nor  is  cough  as  a  rule  a  troublesome  symptom. 
Moderate  pyrexia  may  persist  for  some  little  time.  Provided, 
hozvever,  the  hamothorax  remains  sterile,  these  symptoms 
gradually  subside,  and  the  fluid  is  slowly  absorbed. 

In  some  25  per  cent,  of  chest  wounds  sepsis  unfortunately 
occurs,*  a  complication  twice  as  frequent  when  the  wound  has 
been  caused  by  shell  fragment  as  by  machine-gun  or  rifle 
bullet."  The  infecting  organisms  are  attached  to  the  missile, 
or  are  introduced  with  fragments  of  clothing,  or  come  from 
within  from  the  lacerated  lung.  Of  loi  cases  of  septic  hgemo- 
thorax  investigated  by  Colonel  Elliott  and  Major  Henry,^  in 
rather  less  than  20  per  cent,  the  organisms  isolated  were  the 
pneumococcus,  Pfeiffer's  bacillus,  and  the  M.  tetragenus, 
coming  presumably  from  the  respiratory  tract :  in  the  re- 
mainder, streptococci,  staphylococci,  and  anaerobic  gas-form- 
ing bacilli,  of  which  B.  perfringens  was  the  most  frequent, 
were  found,  gas-forming  organisms  occurring  in  nearly  half 
of  all  the  infected  cases. 

Continued  pyrexia,  restlessness,  a  rapid  pulse,  and  in  some 
cases  a  furred  tongue,  will  suggest  the  occurrence  of  sepsis; 
but  to  make  certain  the  fluid  removed  by  exploratory 
puncture  must  be  examined  bacteriologically,  both  by  staining 
and  culture.  Colonel  Elliott  and  Major  Henry^  found  that 
in  90  per  cent,  of  the  infected  cases  organisms  could  be 
detected  in  films  stained  with  methylene  blue  and  by  Gram's 
method,  and  that  the  finding  of  a  stout  Gram-staining  anthrax- 
like bacillus  was  very  suggestive  evidence  of  anaerobic  infec- 
tion.    Cultures  should,  however,  be  made  in  all  cases. 

In  patients  infected  with  anaerobic  organisms  the  amount  of 


HEMOTHORAX  l6r 

gas  produced  within  the  chest  may  be  considerable,  and  the 
pressure  as  much  as  +  15  to  +20  cm.  of  water.^  Such  cases 
simulate  closely,  and  have  been  mistaken  for  simple  hcsmo- 
pneumothorax  under  the  impression  that  the  air  had  entered 
the  pleura  from  the  pulmonary  wound.  Exploratory  puncture, 
and  the  withdrawal  of  fluid,  often  foul-smelling  and  contain- 
ing infecting  organisms,  will  decide  the  diagnosis. 

The  occurrence  of  sepsis  is  a  grave  complication,  for  whereas 
cases  of  simple  hsemothorax,  which  fortunately  number  three- 
quarters  of  the  whole,  gradually  make  a  complete  recovery, 
of  those  in  which  sepsis  occurs  nearly  half  die.*  ''"'*  ^* 

Treatment. — (a)  Without  Operation. — If  the  haemothorax 
is  small,  reaching  not  higher  than  the  angle  of  the  scapula, 
it  may  be  left  alone.  The  fluid  is  absorbed  and  the  lung  ex- 
pands, and  the  patient  is  in  most  cases  fit  for  duty  in  two  to 
three  months. 

The  same  policy  of  non-interference  may  be  followed  in 
regard  to  larger  effusions,  and  it  is  astonishing  how  quickly 
in  some  cases  the  blood  is  absorbed;  but  statistics  show  that 
recovery  is  hastened  by  aspiration.  This  had  previously  not 
been  regarded  as  correct  treatment  owing  to  the  fear  that 
secondary  hemorrhage  might  result  if  the  compressing  action 
of  the  fluid  were  withdrawn.  Experience  in  the  Great  War 
has,  however,  shown  that  this  fear  is  unfounded,  and  if  the 
effusion  is  a  large  one  it  is  wise  to  aspirate.  As  much  of  the 
fluid  as  possible  should  be  removed,  but  complete  evacuation 
of  the  fluid  is  not  necessary,  since  what  is  left  will  be  dealt 
with  easily  by  the  pleura.  Captain  Fortescue-Brickdale'-  has 
shown  that  of  cases  of  haemothorax  admitted  to  the  Centre  for 
Gunshot  Wounds  of  the  Chest  at  Southmead,  Bristol,  42  per 
cent,  of  the  large  non-aspirated  cases  recovered  completely 
in  two  months  or  less,  and  84  per  cent,  of  those  which  had 
been  aspirated,  showing  the  value  of  aspiration  in  hastening 
recovery.  In  patients  with  a  small  hsemothorax,  about  90  per 
cent,  recovered  in  two  months  or  less,  whether  aspirated 
or  not. 

There  remains  to  consider  certain  rare  cases  of  non-infected 
hcemothorax,  in  which  the  blood-clot  is  a  massive  one,  and 
the  fibrin  not  whipped  out  and  deposited  as  usual  on  the  pleura. 
In  such  cases  aspiration  fails,  or  is  only  successful  to  a  limited 
extent,  and  if  the  hsemothorax  be  a  large  one  it  has  been 

II 


l62  DISEASES   OF  THE  LUNGS  AND  PLEURA 

suggested  that  the  pleura  should  be  opened  in  the  manner  to 
be  described  later,  the  clot  evacuated,  and  the  chest  again 
closed.  In  view  of  the  fact  that,  provided  sepsis  does  not 
supervene,  the  patient  will,  with  the  aid  of  pulmonary  exercises 
and  movements  probably  in  the  end  make  a  complete  recovery, 
this  course  is  hardly  to  be  recommended  as  a  routine 
measure. 

(b)  With  Operation. — We  have  so  far  concerned  ourselves 
with  the  treatment  of  cases  of  haemothorax  following  chest 
wounds  which  remain  uninfected,  and  they  number  about 
75  per  cent,  of  the  whole.  If  properly  treated  the  prognosis 
in  these  cases,  as  we  have  seen,  is  good.  Should  the  haemo- 
thorax become  infected,  rib  resection  and  drainage  must  be 
undertaken,  but  the  outlook  in  such  cases  is  gloomy.  Colonel 
Elliott  "^  ^"d  >i  having  shown  that  nearly  half  the  patients 
succumb,  and  of  the  survivors  one-third  are  more  or  less  dis- 
abled, and  eventually  invalided  from  the  army. 

We  are,  therefore,  faced  with  the  question  whether  by 
surgical  means  we  cannot  prevent  infection,  and  thus  avoid 
the  mortality  associated  v.ith  this  complication.  Any  opera- 
tion for  this  purpose  must  be  undertaken  early,  as  soon  as 
the  patient  has  recovered  from  the  initial  shock,  and  will 
involve  excision  of  the  external  wounds  of  the  soft  parts,  the 
removal  of  splinters  of  ribs  and,  if  necessary,  resection  of 
broken  portions,  the  cleansing  of  the  pleural  cavity  from  blood 
and  clot,  the  extraction  where  possible  of  the  missile,  the 
excision  or  cleansing  of  the  lung  wound,  and,  lastly'  the 
closmg  of  the  chest.  To  effect  these  objects  a  portion  of  rib 
IS  excised,  when,  with  the  help  of  a  retractor,  sufficient  space 
will  be  obtained  for  the  introduction  of  the  hand  within  the 
thorax  and  the  carrying  out  of  the  necessary  manipulations 
Into  the  details  of  the  operation  we  do  not  propose  to  enter 
and  must  refer  the  reader  to  the  writings  of  Colonel  Cask 
and  others,  references  to  which  will  be  found  at  the  end  of 
this  chapter.  We  may  add,  however,  that  severe  though  the 
operation  sounds,  it  is,  in  fact,  attended  with  less  shock  and 
a  smaller  fall  m  blood-pressure  than  is  often  associated  with 
abdominal  operations.' ^"''^^ 

Before  the  War  such  operations  were  rarely  undertaken, 
from  the  belief  that  unless  some  form  of  pressure  chamber, 
such  as  those  devised  by  Sauerbruch  and  Willy  Meyer,  was 


H.EMOTHORAX  l63 

employed  to  prevent  pneumothorax  and  collapse  of  the 
lung  when  the  chest  was  opened,  sudden  death  would  follow. 
Recent  experience  has  shown  that  this  fear  is  groundless,  and 
it  is  estimated  that  during-  the  Passchendaele  fighting  in  the 
summer  and  autumn  of  1917,  38  per  cent,  of  the  chest  wounds 
were  operated  upon  on  the  lines  indicated  above.'*  It  is  clear, 
however,  that  as  sepsis  occurs  in  only  a  quarter  of  the  cases, 
and  as  recovery  in  uninfected  haemothorax  may  be  antici- 
pated, a  rigid  selection  must  be  made,  those  chosen  for 
operation  being  the  cases  in  which,  from  the  nature  of 
the  wound  and  of  the  missile,  sepsis  is  most  likely  to  super- 
vene. In  the  opinion  of  Colonel  Gask,  the  more  important 
indications  for  operation  are:  a  ragged  external  wound; 
compound  fracture  of  the  ribs;  continued  bleeding;  an  open 
wound  leading  into  the  pleural  cavity  with  insuction  of  air 
at  each  inspiration;  the  retention  of  a  large  foreign  body;  and 
pain,  out  of  proportion  to  the  injury,  and  often  due  to  in- 
driven  splinters  of  bone,  which  so  often  lead  to  sepsis. 

We  may  say  in  conclusion  that  there  can  be  no  doubt  that  in 
cases  of  gross  injury,  such  as  those  in  which  the  chest  is  open, 
or  in  which  a  large  foreign  body  is  retained,  or  those  which 
contain  large  indriven  fragments  of  bone  or  clothing,  opera- 
tion is  urgently  demanded  and  often  life-saving.  No  patient, 
on  the  other  hand,  with  a  small  and  clean-cut  wound,  in  whom 
the  foreign  body  is  of  small  dimensions  and  of  smooth  surface, 
and  whose  general  condition  is  good,  should  be  submitted  to 
operation.  Between  these  two  groups  there  must  be  many 
intermediate  cases  in  which  treatment  must  depend  upon  a 
careful  consideration  of  all  the  surrounding  circumstances. 
In  certain  of  these  patients,  provided  the  services  of  a  surgeon 
experienced  in  chest  work  are  available  and  the  conditions 
for  operation  satis  fact  01-y,  a  complete  operation,  as  sketched 
out  above,  may  be  sanctioned,  for  there  can  be  little  doubt  that 
in  the  hands  of  those  who  have  especially  devoted  themselves 
to  chest  work  such  operations  have  led  to  a  saving  of  life, 
though  the  results  from  the  army  as  a  whole,  quoted  by 
Colonel  Elliott,''  are  less  encouraging.  If,  on  the  other  hand, 
the  indications  for  operation  are  not  so  clear,  and  the  surround- 
ing circumstances  less  favourable,  then  it  will  be  better 
merely  to  excise  the  external  wound,  to  remove  fractured 
portions  of  ribS,  and  then  to  close  the  wound,  treating  the 


1 64  DISEASES   OF  THE  LUNGS  AND  PLEURAE 

hemothorax,  if  necessary,  by  aspiration,  and,  should  sepsis 
arise,  to  resect  and  drain  the  pleural  cavity. 

We  may  add  that  we  have  treated  the  subject  dealt  with  in 
this  chapter  at  some  length,  because  there  can  be  no  doubt 
that  the  lessons  learnt  in  the  war  in  regard  to  the  surgery  of 
the  chest  will  be  soon  applied  to  the  maladies  and  injuries  of 
civil  life.  It  is  essential,  therefore,  that  both  physicians  and 
surgeons  should  be  well  acquainted  with  the  subject.  As  an 
illustration  we  may  quote  the  following  case,  which  recently 
came  under  ouf  notice : 

The  patient,  a  dustman,  aged  forty-eight,  during  the  course  of  his 
work  ran  a  needle  into  his  back.  This  disappeared  within  the  chest, 
and  caused  him  at  first  but  little  inconvenience,  but  a  few  days 
later  (on  November  6,  19 19)  he  was  seized  with  sudden  pain  in 
the  right  side,  and  came  to  St.  Bartholomew's  Hospital,  where 
he  was  seen  by  one  of  us.  On  examination  he  was  found  to  have 
surgical  emphysema  over  the  lower  part  of  the  right  lung,  with 
signs  suggestive  of  the  presence  of  a  limited  quantity  of  air  in  the 
pleural  cavity.  The  screen  examination,  however,  revealed  nothing 
abnormal.  He  was  admitted  under  Sir  Archibald  Garrod,  and  an 
X-ray  plate  showed  later  the  presence  of  a  needle  in  the  lower  por- 
tion of  the  right  chest.  On  November  14  Mr.  Gask  operated,  the 
anaesthetic  used  being  chloroform  and  oxygen.  Four  inches  of  the 
sixth  rib  in  the  right  axillary  and  anterior  regions  were  excised  and 
the  chest  fully  opened.  Air  was  found  to  be  present  in  the  pleural 
cavity,  and  in  the  lower  portion  of  the  semi-collapsed  lung  the  needle 
was  at  once  seen,  half  embedded,  half  exposed.  Except  for  a  little 
lymph  round  the  site  of  the  puncture,  the  lung  appeared  healthy. 
The  needle  was  extracted  and  the  wound  closed.  The  operation 
was  followed  by  a  small  collection  of  clear  serous  fluid  at  the  right 
base  and  a  low  degree  of  pyrexia  lasting  twelve  days,  but  recovery 
was  otherwise  uneventful. 

This  case  shows  the  value  of  such  methods  of  surgical 
treatment,  for  there  can  be  little  doubt  that  had  the  case  been 
left  alone,  suppuration,  with  its  accompanying  dangers,  would 
have  ensued. 

REFERENCES. 

*  "  A  Case  of  a  Rapidly  Fatal  Haemopneumo thorax,  apparently  due  to 
the  Rupture  of  an  Emphysematous  Bnlla,"  by  G.  Newton  Pitt,  M.D., 
Transactions  of  the  Clinical  Society  of  London,  igoo,  vol.  xxxiii.,  p.  95. 

^  "  Haemothorax,"  by  Colonel  Sir  John  Rose  Bradfopd,  K.C.M.G.,  C.B., 
F.R.S.,  and  Captain  T.  R.  Elliott,  F.R.S.,  The  British  Journal  of  Surgery, 
vol.  iii.,  No.  10,  1915,  p.  247. 


H.EMOTHORAX  1 65 

^  ■'  Infection  of  Haemothorax  by  Anaerobic  Gas-Producing  Bacilli " 
(A  Report  to  the  Medical  Research  Committee),  by  Lieut. -Colonel  T.  R. 
Elliott,  F.R.S.,  and  Captain  Herbert  Henry,  M.D.,  British  Medical  Journal, 
March  31  and  April  7,  1917. 

^  "  Le  Collapsus  pulmonaire  contro-lateral  dans  les  Plaies  de  Poitrine," 
par  le  Colonel  Sir  John  Rose  Bradford,  K.C.M.G.,  Bulletins  et  Mcmoires 
de  la  Societe  Medicate  des  Hofitaux  de  Paris,  Mai  31,  1917. 

^  "  On  Gunshot  Injuries  of  the  Chest  with  Especial  Reference  to  Hasmo- 
thorax,'"  by  Sir  John  Rose  Bradford,  K.C.M.G.,  C.B.,  F.R.S.,  British 
Medical  Journal,  August  4,  1917. 

"  "  Some  Statistical  Results  of  the  Treatment  of  Chest  Wounds,"  by 
T.  R.  Elliott,  F.R.C.P.,  F.R.S.,  The  Lancet,  September  8,  1917,  ii.,  p.  371. 

'  "  Remarks  on  Penetrating  Gunshot  Wounds  of  the  Chest,  and  their 
Treatment,"  by  G.  E.  Cask,  D.S.O.,  F.R.C.S.,  and  K.  D.  Williamson, 
M.D.,  M.R.C.P.,  British  Medical  Journal,  December  15,  1917. 

*  "War  Surgery  of  the  Chest,"  by  Captain  A.  L.  Lockwood,  M.C.,  and 
Captain  J.  A.  Nixon,  British  Medical  Journal,  January  26,  and 
February  2,  1918. 

°  Lemons  de  Chirurgie  de  Guerre,  Publiees  sous  la  direction  de 
CI.  Regaud  (Service  de  Sante  Militaire,  centre  d'Etudes  et  d'Enseigne- 
ment  Medico-chirurgical  de  Bouleuse).     Masson  et  Cie,  Paris,  1918. 

'"  "  Massive  Collapse  of  the  Lung  as  a  result  of  Gunshot  Wounds,  with 
Especial  Reference  to  Wounds  of  the  Chest,"  by  John  Rose  Bradford, 
Quarterly  Journal  of  Medicine,  vol.  xii.,  Nos.  45  and  46,  October,  igi8- 
January,  1919. 

"  "  The  Early  Treatment  of  Gunshot  Wounds  of  the  Chest,"  by  Colonel 
G.  E.  Gask,  D.S.O.,  Surgery,  Gynecology,  and  Obstetrics,  January,  1919, 
pp.   12-16. 

'-  "  Statistical  and  Clinical  Report  on  600  Cases  of  Gunshot  Wounds  of 
the  Chest,"  by  J.  M.  Fortescue-Brickdale,  M.D.,  M.R.C.P.,  Medical 
Research  Committee,  Statistical  Report,  No.  4,  February  27,  191 9. 

'■''  "Remarks  on  Chest  Wounds  from  a  Physician's  Notebook,"  by  J.  A. 
Nixon,  C.M.G.,  M.D.,  F.R.C.P.,  British  Medical  Jotirnal,  April  5,  1919. 

1'  "  Gunshot  Wounds  if  the  Chest,"  by  Colonel  T.  R.  Elliott,  F.R.S. 
Printed  by  the  British  Medical  Association.  Abstract  in  British  Medical 
Journal,  April,  1919,  i.,  p.  442. 

"  "  Surgical  Aspects  of  Gunshot  Wounds  of  the  Chest,"  by  Colonel  G.  E 
Gask,  C.M.G.,  D.S.O.,  British  Medical  Journal,  April,  1919,  i.,  p.  445. 


CHAPTER  XI 

CHYLOTHORAX 

The  occurrence  of  effusions  into  the  serous  cavities  which 
have  an  appearance  resembling  that  of  milk,  but  which  are 
non-purulent  in  nature,  has  been  known  since  the  year  1633, 
when  Bartolet'  described  a  pleural  effusion  of  this  character, 
ft  is  only  in  comparatively  recent  years,  however,  that  the 
subject  has  attracted  much  attention.  .Such  collections  are 
met  with  most  often  in  the  peritoneum,  less  frequently  in 
the  pleura,  and  only  very  rarely  in  the  pericardium.  They 
sometimes  occur  simultaneously  in  both  peritoneum  and 
pleura.  Chylothorax  is  undoubtedly  a  rare  condition,  and 
in  a  recent  paper  Dr.  Mackenzie  Wallis  and  Dr.  Scholberg- 
were  only  able  to  collect  sixty  cases  which  have  been  recorded 
since  the  year  i860. 

Effusions  of  this  nature  may  be  divided  into  two  groups  • 
(i)  True  chylothorax,  (2)  Pseudo-chylothorax,  in  both  of 
which  the  naked-eye  appearance  of  the  fluid  may  be  very 
similar.  In  the  first  variety,  the  true  chylous  variety,  the 
fluid  has  become  milky  owing  to  the  fact  that  as  a  result  of 
injury  or  pressure  upon  the  thoracic  duct,  a  rupture  of  its 
walls  has  occurred,  and  chyle  has  found  its  way  into  the 
pleural  cavity.  The  milky  colour,  in  fact,  is  due  to  the 
presence  of  free  fat.  In  the  pseudo-chylons  form,  on  the 
other  hand,  as  Dr.  Scholberg  and  Mr.  Mackenzie  Wallis  have 
shown,  the  milky  appearance  results  from  the  presence  in 
the  pleural  fluid  of  a  special  compound  or  "complex,"  a 
lecithin-globulin  or,  as  in  the  case  recorded  in  this  chapter,  a 
cholesterin-globulin  compound,  of  which  we  shall  speak  more 
fully  later.  The  physical  and  chemical  characters  of  the 
fluids  in  these  two  groups  are  somewhat  different,  and,  fol- 
lowing the  investigations  by  Dr.  Scholberg  and  Dr.  Mac- 
kenzie Wallis,  may  be  briefly  given  as  follows : 

166 


CHYLOTHORAX 


167 


The  True  Chylous  Variety. 

1.  The  fluid  tends  to  accumulate 
rapidly,  and  in  consequence  large 
quantities  are  removed  by  para- 
centesis. 

2.  In  colour  it  is  generally  yellow- 
ish-white. Emulsification  is  not 
perfect. 

3.  The  degree  of  ofalescence  is 
more  or  less  constant  at  successive 
tappings. 

4.  The  fluid  -possesses  an  odour 
corresponding  to  the  odour  of  the 
food  digested. 

5.  Putrefaction  occurs  on  stand- 
ing. 

6.  A  creamy  layer  generally  forms 
on  standing,  owing  to  the  amount  of 
fat  present. 

7.  The  specific  gravity  generally 
exceeds  1-012. 

8.  The  freezing  point  is  depressed 
about  -0-51°  C,  the  figure  thus 
approximating  that  for  chyle. 

9.  No  change  occurs  on  filtering 
through  filter  paper.  On  centrifu- 
galisation  the  fluid  creams  and  may 
partially  clear.  On  filtering  through 
a  Pasteur  candle  the  milky  colour 
remains. 

10.  Microscopically,  many  fine  fat 
globules,  staining  with  osmic  acid 
and  Sudan  III.  are  seen,  but  very 
few  cellular  elements. 


11.  On  shaking  the  fluid  with 
ether  and  a  little  fotash  the  fat  is 
dissolved  and  the  fluid  clears. 

12.  The  total  solids  vary  consider- 
ably, but  are  usually  greater  than 
4  per  cent. 

13.  The  total  protein-content  gener- 
ally exceeds  3  grm.  per  cent.,  and 
of  this  amount  serum-albumen  forms 
the  largest  fraction,  globulin  occur- 
ring only  in  traces. 


The  Pseudo-chylous  Variety. 

1.  The  fluid  collects  more  slowly, 
the  volume  of  the  fluid  varying 
with  the  exciting  pathological  con- 
dition. 

2.  In  colour  it  is  pure  milky-white. 
The  solution  forms  an  almost  perfect 
emulsion. 

3.  The  opacity  often  increases  or 
diminishes  at  successive  tappings; 
and  may  entirely  disappear. 

4.  The  fluid  is  odourless. 


5.  It  long  resists  putrefaction, 
probably  owing  to  the  presence  of 
lecithin. 

6.  A  cream  may  or  may  not  form, 
and  this  does  not  affect  the  opales- 
cence. A  sediment  frequently  settles 
out. 

7.  The  specific  gravity  is  gener- 
ally less  than  1-012. 

8.  The  depression  of  the  freezing 
point  ranges  from  -o- 56°  to -0-61°  C, 
thus  corresponding  to  the  figures 
for  blood-serum. 

9.  No  change  occurs  on  filtering 
through  paper,  nor  on  centrifugali- 
sation ;  but  on  filtering  through  a 
Pasteur  candle  the  fluid  clears. 


10.  Microscopically,  the  quantity 
of  free  fat  is  variable ;  numerous 
fine,  highly  refractive  granules 
(lecithin-globulin  complex)  are  seen, 
which  do  not  stain  lihe  fat. 

Cellular  elements  may  be  numerous 
and  often  contain  fat ;  sometimes 
they  are  scanty. 

11.  Shaking  with  ether  and  potash 
may  dissolve  some  fat,  but  the 
opalescence  remains. 

12.  The  total  solids  rarely  exceed 
2  per  cent. 

13.  The  protein-content  varies  be- 
tween I  and  3  per  cent.,  the  serum- 
globulin  occurring  in  appreciable 
quantities. 


i68 


DISEASES   OF  THE  LUNGS   AND  PLEURA 


The  True   Chylous    Variety. 

14.  Mucinoid  substances  are 
absent. 

15.  The  jni-content  is  generally 
high,  varying  from  0-4  to  4  per  cent. 
The  fat  corresponds  in  all  its  proper- 
ties to  the  fat  contained  in  food. 

16.  Of  the  lipines,  cholesterin  is 
invariably  found,  and  lecithin  only 
occurs  in  traces. 

17.  There  is  no  evidence  of  the 
presence  of  a  lecithin-globulin  com- 
plex. 


The  Pseudo-chylous  Variety. 

14.  Mucinoid  substances  are  some- 
times present. 

15.  The  fat-content  is  generally 
loiv  and  may  be  present  in  traces 
only;  in  its  melting  point  and 
chemical  composition  it  proves  to  be 
pathological  fat. 

16.  The  most  characteristic  li-pine 
is  lecithin;  cholesterin  is  occasion- 
ally present. 

17.  The  lecithin  is  mainly  com- 
bined zvith  the  globulin,  and  the 
suspension  of  this  complex  is  the 
cause  of  the  milkv  appearance.  If 
this  complex  be  removed  by  filtra- 
tion through  a  Pasteur  filter,  or  be 
precipitated  by  half-saturation  of 
the  fluid  with  ammonium  sulphate, 
or  as  the  result  of  the  removal  of 
the  salts  by  dialysis,  the  opalescence 
at  once  vanishes. 

18.    The    salts    and    organic    sub-  18.    The    salts    and    organic    sub- 
stances   present     approximate    the  stances   correspond   closely   to   those 
values  found  for  chyle  obtained  from  of  lymph  and  serous  fluids, 
the  thoracic  duct. 

Note. — The  figures  given  for  specific  gravity,  total  solids,  and  total 
proteiji-content  must  be  taken  as  relative  only,  and  may  be  found  con- 
siderably higher  if  the  pleura  be  the  seat  of  much  inflammatory  change. 

We  thus  see  that  in  the  true  chylous  variety  the  opales- 
cence is  due  to  the  presence  of  chyle,  and  to  the  large  amount 
of  fat  present,  under  the  microscope  many  fine  fat  globules 
being  seen,  which  stain  with  osmic  acid  and  Sudan  III.,  and 
often  show  Brownian  movements.  If  the  fat  be  removed  by 
shaking  with  ether  and  potash,  the  opalescence  vanishes.  In 
the  pseudo-chylous  form,  on  the  other  hand,  though  fat  may 
be  present,  the  opalescence  is  not  due  to  it,  and  does  not 
disappear  on  shaking  with  ether  and  potash,  but  results  from 
the  suspension  in  the  fluid  of  a  combination  of  globulin  with 
lecithin  (or  cholesterin),  which  appears  under  the  microscope 
as  numerous  fine,  highly  refractive  granules,  which  do  not 
stain  like  fat.  Dr.  Scholberg  and  Dr.  Mackenzie  Wallis 
proved  this  by  half  saturating  the  milky  fluid  with  ammonium 
sulphate,  a  precipitate  being  produced,  which  on  investiga- 
tion proved  to  be  composed  of  globulin  and  lecithin.  On 
filtering   the    precipitate   a   clear   fluid    resulted.     A    similar 


CHYLOTHORAX  1 69 

result  also  followed  the  filtration  of  the  milky  fluid  through 
a  Pasteur  filter,  which  kept  back  the  lecithin-globulin  com- 
plex, and  yielded  a  clear  filtrate.  That  the  abo^e  complex  is 
held  in  suspension  by  the  inorganic  salts  present  was  proved 
by  exposing  the  fluid  to  dialysis.  As  the  salts  were  in  this 
way  removed  the  complex  was  precipitated  and  the  fluid 
cleared. 

Etiology. — Of  the  two  varieties  of  chylothorax,  true  and 
false,  the  peeudo-chylous  form  is  probably  the  one  most 
frequently  met  with. 

The  causes  which  produce  chylothorax  of  the  true  chylous 
type  may  be  reduced  to  two  : 

(a)  Increased  pressure  within  the  thoracic  duct,  for  the 
most  part  the  result  of  obstruction  due  to  malignant  growth 
(more  rarely  filarial  in  nature),  leading  to  backward  flow  of 
the  chyle  along-  the  pulmonary  and  pleural  lymphatics,  whence 
access  to  the  pleural  cavity  is  easy. 

(b)  External  violence  resulting  in  ruptttre  of  the  thoracic 
duct  and  presumably  of  the  pleura. 

Of  these  two  causes  the  former  is  the  more  important. 

The  pseudo-chylous  form  would  seem  to  occur  most  often 
in  connection  with  malignant  disease  and  tuberculosis^  and 
it  has  been  suggested  that  the  lecithin,  the  presence  of  which 
in  the  fluid  we  have  seen  to  be  so  important,  is  set  free  as  the 
result  of  cell-destruction  taking  place  during-  the  course  of 
the  disease.  The  lecithin  subsequently  finds  its  way  into  the 
serous  cavity,  where  it  unites  with  serum-globulin  to  form  the 
complex  which  produces  the  milky  appearance. 

A  study  of  the  literature  shows  that,  taking  all  cases  of 
chylothorax  together,  nearly  half  are  found  to  be  dependent 
upon  new  growth,  tubercle  and  injury  being  the  next  most 
common  causes. 

Chylothorax  occurs  in  either  sex  and  at  all  ages.  It  is, 
however,  somewhat  more  common  in  the  male,  partly  perhaps 
as  the  result  of  the  greater  liability  of  males  to  injury. 

As  regards  age,  the  youngest  case  recorded  is  that  of  a 
child,  aged  five  months,  the  condition  being  the  result  of 
injury;  the  oldest  patient  was  aged  sixty-seven,  the  chylo- 
thorax in  her  case  following  upon  new  growth.  Thirty-one 
cases  out  of  forty-eight  occurred  between  the  ages  of  twenty 
and  fifty. 


I/O  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Sympt07ns.— The  symptoms  of  chylothorax  are  in  no  wise 
distinctive.  The  side  gradually  fills  with  fluid,  and,  if  suffi- 
cient in  amount,  displacement  of  the  heart  follows.  The  tem- 
perature is  generally  not  raised,  and  the  patient  complains  of 
little  or  nothing  beyond  some  shortness  of  breath  on  exertion. 
It  is  not  indeed  until  an  exploratory  puncture  is  made  that 
the  peculiar  character  of  the  fluid  is  recognised.  Its  nature 
might  be  suspected,  however,  if  a  fluid  of  like  character  had 
already  been  withdrawn  from  the  peritoneum. 

Prog>wsis. — The  prognosis  in  a  case  of  chylothorax  of 
whatever  type  is  serious,  the  primary  cause  of  the  condition, 
whether  growth,  tuberculosis,  or  injury,  being  in  itself  of 
serious  augury.  The  presence  of  the  milky  effusion  does  not 
materially  add  to  the  gravity  of  the  condition,  unless  the 
resulting  respiratory  distress  calls  for  repeated  paracentesis, 
in  which  case  the  drain  of  fluid  from  the  circulation  may 
hasten  the  downward  course  of  the  original  malady. 

Recovery,  however,  in  cases  not  malignant  in  nature,  is  by 
no  means  unknown.  It  has  been  met  with  in  many  cases 
produced  by  injury,  and  may  occur  in  others  secondary  to 
disease.  Thus  in  a  case  recorded  by  Mr.  Penn  Milton,^  which 
occurred  in  a  patient  suffering  from  early  phthisis,  recovery 
ensued  after  a  single  aspiration,  in  which  300  ounces  of  milky 
fluid  were  removed  from  the  right  side  of  the  chest.  Again, 
in  a  boy,  aged  thirteen,  suffering  from  Hodgkin's  disease, 
whom  one  of  us  had  the  opportunity  of  seeing  whilst  under 
the  care  of  Dr.  Ormerod'  at  St.  Bartholomew's  Hospital,  the 
chylothorax — in  this  case  of  the  true  chylous  variety  and  on 
the  right  side — disappeared  after  three  aspirations  had  been 
performed.  In  this  and  similar  cases  the  recovery  is  probably 
due  to  the  enlargement  of  the  anastomosing  lymph  branches, 
which  connect  the  thoracic  with  the  right  lymphatic  duct. 

Diagnosis. — The  milky  fluid  withdrawn  in  cases  of  chylo- 
thorax has  been  mistaken  for  thin  pus,  and  we  have  known 
resection  advised  in  such  a  case  before  the  mistake  was 
realised.  The  distinction  is  readily  made  if  attention  be  given 
to  the  following  points.  If  the  fluid  be  pus,  (i)  numerous 
cells  will  be  seen  under  the  microscope,  the  number  corre- 
sponding to  the  opalescence.  (2)  Centrifugalisation  will  yield 
a  deposit  of  cells  at  the  bottom  of  the  tube  and  a  clear 
supernatant  liquid.     (3)   Filtration  through  filter  paper  will 


CHYLOTHORAX  171 

keep  back  the  cells  and  yield  a  clear  filtrate.  In  all  these 
points  the  purulent  fluid  differs  from  the  milky  fluid  of 
chylo  thorax. 

We  may  perhaps  mention  here,  as  causing-  a  possible  error 
in  diagnosis,  that  anomalous  condition  described  by  Dr. 
Samuel  West,*  in  which  the  pleura  contained  several  pints  of 
cream-like  fluid,  the  appearance  of  which  was  due  to  numerous 
bright  refractive  globules  composed  chiefly  of  calcium  phos- 
phate. At  the  autopsy,  which  was  made  by  one  of  us, 
numerous  larger  irregular  masses  of  similar  structure  were 
found,  mostly  free,  but  some  attached  to  the  pleura,  giving 
the  pleural  cavity,  especially  in  its  basal  portion,  the  appear- 
ance of  a  "  chalk-pit." 

Treatment. — In  chylothorax,  whether  of  the  true  or  false 
variety,  we  should  not  be  in  too  great  a  hurry  to  intervene. 
In  the  true  chylous  form,  if  the  heart  be  much  displaced  and 
dyspnoea  urgent,  paracentesis  must  be  performed;  other- 
wise it  is  best  to  wait,  and  to  trust  to  the  establishment  of 
the  collateral  circulation.  As  we  have  seen,  this  may  occur 
even  after  one  or  two  tappings.  In  cases  of  the  pseudo- 
chylous variety  the  effusion  should  be  treated  on  ordinary 
lines  as  though  it  were  a  simple  serous  effusion,  the  milky 
character  altering  neither  the  outlook  nor  the  treatment  of 
the  condition.  Aspiration  should  therefore  be  performed 
from  time  to  time  as  occasion  requires. 

Notes  of  a  Case  of  Pseudo-chylothorax   occurring  in 
A  Patient  suffering  from  Hodgkin's    Disease.*^ 

We  may  perhaps  focus  what  we  have  said  by  briefly  describ- 
ing- the  following  case  of  pseudo-chylothorax,  the  patient 
having  been  under  our  care  in  the  Brompton  Hospital : 

A.  H.,  ai^ed  thirty-five,  railway  guard,  was  admitted  into  the 
Brompton  Hospital  on  September  12,  1913,  complaining  of  weakness 
and  pains  in  his  chest.  He  had  suffered  in  1901  from  left-sided 
pneumonia  and  pleurisy,  but  from  this  he  completely  recovered  and 
remained  well  until  March,  1913,  when  he  began  to  complain  of 
debility.  He  continued  his  work  until  July,  when,  owing  to  increas- 
ing weakness  and  pain  in  the  left  side  of  the  chest,  he  was  obliged 
to  relinquish  it.  About  this  time  also  he  began  to  complain  of  cough 
and  expectoration  and  to  suffer  from  shortness  of  breath  and  night 
sweats.  There  was  some  little  loss  of  weight.  On  September  12 
he  was  admitted  into  the  hospital. 


1/2  DISEASES   OF   THE  LUNGS   AND   PLEURA 

Condition  on  Admission.— The  patient  looked  ill.  His  temperature 
was  swinging,  rising  at  night  to  between  ioo°  and  ioi°  F.  Pulse,  120. 
Respiration,  32. 

On  examining  the  chest  the  signs  of  a  large  left-sided  pleural  efifusion 
were  observed.  The  left  side  was  dull  from  apex  to  base,  with  very 
weak  breath-sounds  and  diminished  vocal  vibrations ;  the  heart  was 
displaced  about  a  finger's  breadth  to  the  right  of  the  sternum.  The 
note  at  the  right  apex  was  slightly  impaired,  but  no  added  sounds 
were  audible.  The  abdomen  contained  some  little  free  fluid.  The 
spleen  was  markedly-  enlarged,  the  organ  reaching  down  to  the 
umbilicus  and  presenting  a  very  definite  edge.  There  was  no  enlarge- 
ment of  the  external  lymph  glands.  The  bowels  were  somewhat 
loose.     The  urine  and  other  organs  were  natural. 

On  September  13,  the  day  following  his  admission,  the  left  side 
was  explored  and  a  syringe  full  of  milky  fluid  withdrawn.  This 
presented  a  pale  yellowish-white  colour,  and  suggested  at  first  sight 
pus,  but  proved  on  analysis  (see  p.  174)  to  be  a  pseudo-chyothorax. 
On  September  19  aspiration  was  performed,  and  49  ounces  of  a  similiar 
fluid  were  evacuated.  The  note  now  became  resonant  in  front  to 
below  the  nipple,  but  the  breath-sounds  remained  weak. 

The  opalescent  fluid  withdrawn  was  sterile,  and  gave  the  following 
differential  count  :  80  per  cent,  small  lymphocytes,  10  per  cent,  large 
lymphocytes,  and  10  per  cent,  polymorphonuclear  cells ;  and  as  about 
this  time  tubercle  bacilli  were  found  in  the  sputum,  the  case  was 
considered  to  be  one  of  pulmonary  tuberculosis,  with  tuberculous 
pleurisy,  in  which  the  fluid  presented  the  pseudo-chylous  character. 
The  spleen  was  also  regarded  as  tuberculous  in  nature,  studded  in 
all  probability  with  caseous  masses,  although  the  rarity  of  such  a 
condition  in  the  adult  was  fully  recognised. 

After  the  paracentesis  the  temperature  continued  hectic  and  the  side 
rapidly  refilled,  the  heart  becoming  again  displaced,  and  the  left  side 
measuring  |  inch  more  than  the  right. 

On  September  26  paracentesis  was  performed  a  second  time,  and 
three  pints  of  milky  fluid  withdrawn.  The  cytological  ,<:ount  was  very 
similar  to  that  found  on  September  19;  no  tubercle  bacilli  could  be 
discovered  in  the  fluid.  The  blood-count  on  October  2  showed 
3,700,000  red  cells ;  haemoglobin,  80  per  cent. ;  leucocytes,  4,000.  The 
differential  count  showed  some  diminution  in  the  lymphocytes,  with 
corresponding  increase  in  the  polymorphonuclear  cells,  but  was  other- 
wise normal. 

On  October  7  paracentesis  was  again  performed,  and  three  pints 
of  opalescent  fluid  withdrawn.  On  cultivation  this  proved  to  be  sterile, 
and  no  tubercle  bacilli  could  be  found  in  it.  Cytological  examination 
showed  it  to  contain  :  small  mononuclears,  81  per  cent. ;  large  mononu- 
clears, 10  per  cent.  ;  polymorphonuclears,  9  per  cent. 

The  temperature  still  continued  to  swing,  reaching  100°  F.  at 
night,  but  the  patient  suffered  little.  Towards  the  end  of  the 
month  dyspnoea  returned  (respirations,  32;  pulse,  128),  and  as 
the  heart  was  displaced  paracentesis  was  performed  on   October  29 


CHYDOTHORAX  I73 

for  the  fourth  time,  three  pints  of  the  opalescent  fluid  being  removed. 
From  this  date  the  patient  gradually  became  weaker  and  was 
troubled  with  diarrhoea.  The  chest  filled  again,  and  there  was  some 
dyspnoea,  but  no  real  distress.  At  the  end  of  November  he  became 
worse,  with  delirium  and  incontinence  of  urine  and  faeces,  and  died 
peacefully  at  7  p.m.  on  November  30. 

Post-Mortem  Examination.— The  autopsy,  made  by  Dr.  R.  A. 
Young,  showed  that  the  diagnosis  of  tuberculosis  made  during  life, 
based  largely  on  the  reported  finding  of  tubercle  bacilli  in  the  sputum, 
was  incorrect.  No  evidence  of  tuberculosis  could  be  discovered  in 
lungs,  pleurjE,  or  spleen,  but  the  patient  was  found  to  be  the  subject 
of  a  diffuse  asd  extensive  growth,  thought  at  first  to  be  sarcomatous, 
but  which  microscopical  examination  proved  to  be  lymphadenomatous 
in  nature.     The  following  are  the  more  detailed  findings  : 

Body. — Much  emaciated. 

Chest. — On  opening  the  chest  the  right  pleural  cavity  was  found  to 
contain  8  ounces  of  clear  serous  fluid — the  pleura  itself  was  natural. 
The  left  pleural  cavity  contained  about  two  pints  of  slightly  opalescent 
fluid,  much  less  milky  than  on  the  occasion  of  the  last  paracentesis, 
a  month  before  death.  Dense  adhesions  were  present  at  the  apex, 
and  one  band  of  adhesions  was  present  over  the  lower  lobe,  but  the 
pleura  was  elsewhere  shiny  and  appeared  natural. 

The  Lungs. — The  left  lung  was  markedly  collapsed,  and  on  section 
was  slaty  blue  and  airless.  The  right  lung  showed  a  considerable 
degree  of  emphysema,  and  was  very  oedematous  throughout ;  a  few 
adhesions  were  present  at  the  apex.  No  tuberculous  foci  were  found 
in  either  lung.  The  larynx,  trachea  and  bronchi  were  natural.  The 
bronchial  and  anterior  mediastinal  glands  were  markedly  enlarged, 
and  showed  secondary  deposits  of  growth,  but  no  naked-eye  evidence 
of  tubercle.     The  pericardium  and  heart  were  natural. 

On  removing  the  heart  and  lungs  a  mass  of  growth,  of  firm  con- 
sistency, was  seen  to  extend  over  the  four  lower  thoracic  vertebrae, 
and  to  form  a  sheath  over  the  lower  and  contiguous  portion  of  the 
thoracic  aorta.  It  also  extended  for  some  little  distance  under  the 
adjacent  portion  of  the  left  pleura.  The  thoracic  duct  was  not  dis- 
covered, being  embedded  in  the  growth  around  the  aorta  and  in  the 
dense  adhesions  at  the  apex  of  the  left  lung. 

Abdomen. — The  peritoneal  cavity  contained  about  100  ounces  of 
blood-stained  serous  fluid.  On  removing  the  contents  a  large  mass 
of  growth  was  found,  nearly  2  inches  in  thickness,  surrounding  the 
whole  of  the  abdominal  aorta  and  the  common  iliac  arteries.  The 
growth  extended  widely  in  all  directions  behind  the  peritoneum  and 
infiltrated  the  bodies  of  the  second  and  third  lumbar  vertebrae,  which 
presented  in  parts  a  rough  worm-eaten  appearance.  The  left  suprarenal 
gland  was  embedded  in  the  growth  and  infiltrated  by  it. 

The  liver  was  enlarged  and  contained  numerous  soft  vascular 
growths.  A  gland,  enlarged  by  growth,  lay  upon  the  gall-bladder, 
and  others  in  a  similar  condition  were  seen  along  the  lesser  curvature 
of  the  stomach.     Those  along  the  upper  margin  of  the  pancreas  wer^ 


174  DISEASES  OF  THE  LUNGS   AND  PLEURA 

much  enlarged  and  occupied  by  growth,  but  the  pancreas  itself  was 
free. 

The  spleen  was  greatly  enlarged,  weighing  22  ounces.  Its  surface 
was  irregular  from  the  presence  of  numerous  growths  within  its 
surface.  On  section  it  was  found  to  be  riddled  with  growths,  which 
were  dark  in  colour,  probably  from  haemorrhage  into  their  substance. 

The  stomach,  intestines,  bladder,  prostate  and  testicles  were 
normal ;  the  kidneys  were  enlarged  and  slightly  fatty.  •  The  recepta- 
culum  chyli  could  not  be  found,  all  the  structures  in  its  neighbour- 
hood being  densely  infiltrated  with  growth. 

The  naked-eye  appearances,  thus  described,  suggested  that  the 
disease  was  a  retroperitoneal  sarcoma  with  numerous  secondary 
growths.  The  following  report,  however,  by  Dr.  Young  upon  the 
microscopical  character  of  the  sections  showed  that  in  fact  it  was 
a  case  of  lympha^enoma  : 

Report  upon  the  Microscopical  Characters  of  the  Growth 
BV  Dr.  R.  a.  Young,  M.D.,  F.R.C.P. 

"  A  Portion  of  the  Main  Retroperitoneal  Mass  of  Growth.- — The 
section  presented  the  characteristic  appearances  of  true  Hodgkin's 
disease  or  lympho-granuloma ;  the  reticulum  was  abundant,  and 
there  were  numerous  typical  giant  cells.  Under  the  one-twelfth  power 
some  of  the  cells  in  the  reticulum  showed  eosinophile  granulation. 
There  was  very  little  degenerative  change,  but  some  haemorrhage  was 
observed  in  parts  of  the  section. 

Sections  of  mediastinal  and  bronchial  glands,  and  of  the  growths 
in  the  liver,  spleen,  and  left  suprarenal  showed  a  similar  miscroscopical 
character." 

Report  by  Dr.   R.   L.   Mackenzie  Wallis  upon  the  Milky   Fluid 
withdrawn  from  the  Pleural  Cavity. 

"  The  fluid  was  milky  in  appearance,  presenting  a  pale  yellowish- 
white  colour.  It  was  odourless,  and  presented  a  specific  gravity  of 
102 1.     Reaction  alkaline. 

It  did  not  cream  on  standing.  The  opalescence  was  not  removed 
by  filtration  or  centrifugalisation,  but  was  removed  by  passage  through 
a  Pasteur  filter.     Chemically  its  composition  was  as  follows  . 

Total  solids 
Inorganic  ash 
Serum  albumen    ... 
Serum  globulin    ... 
Total  nitrogen 
Fat  and  lecithin  ... 
Cholesterol 
Sugar 

'Nucleo-proteid 
Mucin     ... 
Sodium  chloride  ... 
Ratio    of    albumen    to    glo- 
bulin, nearly     ... 


4-560  per  cent. 
0-821 

2-020 

„  )  Total  protein - 
»  )    3'57  P^r  cent. 
>) 
J) 

r-55 
0-58 

o-o6 

0-052 
absent. 

J) 

absent. 

a  trace 

only. 

0-43  per  cent. 

CHYLOTHORAX  175 

Conclusion. — The  fluid  in  its  physical  properties  behaves  exactly  like 
a  pseudo-chylous  fluid — i.e.,  it  does  not  cream,  the  opalescence  is  un- 
affected by  filtration  or  centrifugalisation,  but  is  removed  by  passage 
through  a  Pasteur  filter.  The  opalescence  is  apparently  due  to  the 
occurrence  of  globulin  united  to  cholesterol  and  lecithin,  the  former 
being  in  greater  quantity.  In  its  chemical  composition  and  physical 
properties  the  fluid  behaves  exactly  like  a  pseudo-chylous  fluid,  but 
differs  from  those  previously  described  in  the  preponderance  of 
cholesterol  over  lecithin — the  figure  for  the  lecithin  being  too  small 
to  warrant  inclusion  as  a  definite  entity. 

The  fluid  would  appear,  therefore,  to  be  a  true  pseudo-chylous  pleural 
fluid,  and  not  derived  from  rupture  or  obstruction  of  the  thoracic  duct." 

REFERENCES. 

'  Quoted  by  Dr.  Rotmann  :  "  Ueber  fetthaltige  Ergiisse  in  den  grossen 
sevosen  Hohlen,"  von  Dr.  Rotmann,  Zeitschrift  fur  Klinische  Medicin. 
Berlin,  1S97,  p.  416. 

^  "  On  Chylous  and  Pseudo-chylous  Ascites,"  Parts  I.  and  II.,  with 
Bibliography,  by  R.  L.  Mackenzie  Wallis  and  H.  A.  Scholberg,  The 
Quarterly  Journal  of  Medicine,  April,  1910,  vol.  iii.,  No.  11,  p.  301;  and 
January,  igii,  vol.  iv.,  No.  14,  p.   153. 

*  "A  Case  of  Chylothorax,"  by  J.  Penn  Milton,  M.R.C.S.  (Eng.), 
L.R.C.P.,  British  Medical  Journal,  1907,  vol.  ii.,  p.   1210. 

*  "  Clinical  Lecture  on  a  Case  of  Lymphadenoma  (Hodgkin's  Disease), 
with  Chylothorax,"  by  J.  A  Ormerod,  M.D.,  St.  Bartholomew'' s  Hospital 
Journal,  April,   1907,  p.  98. 

*  "  A  Case  in  which  the  Pleura  contained  several  Pints  of  Calcareous 
Mortar-like  Fluid,"  by  Samuel  West,  M.D.,  Transactions  of  the  Clinical 
Society  of  London,  1906,  vol.  xxxix.,  p.  42. 

^  "  Chylothorax,  with  Notes  of  a  Case  of  the  Pseudo-chylous  Variety," 
by  P.Horton-Smith  Hartley,  C.V.O.,  M.D.,  F.R.C.P.,  St.  Bartholomeiv' s 
Hosfital  Journal,  January,  191 5,  p.  58. 


CHAPTER  XII 

BRONCHITIS— BROISCHIAL  CATARRH 

Acute  bronchitis  consists  in  an  active  inflammation  of  the 
mucous  membrane  of  some  portion  of  the  bronchial  tract. 

Etiology. — The  disease  is  especially  prevalent  in  northern 
latitudes,  in  exposed  and  elevated  situations,  and  in  districts 
where  moisture  of  atmosphere  as  Avell  as  a  low  temperature 
and  cold  winds  prevail.  In  our  British  climate  these  condi- 
tions are  but  too  well  fulfilled,  and  bronchitis  is  endemic 
amongst  us. 

January,  our  coldest  and  dampest  month,*  is  that  in  which 
it  is  most  prevalent;  but  from  the  variable  temperature  and 
cold  winds  which  characterise  our  spring,  bronchitis  is  then 
also  of  common  occurrence.  In  our  autumn  it  is  less  preva- 
lent, although  persons  with  a  tendency  to  recurrent  bronchitis 
are  often  attacked  each  year  as  the  colder  weather  comes 
round. 

The  incidence  of  bronchitis  is  influenced  by  age,  sex,  occu- 
pation, and  conditions  of  life,  chiefly  in  so  far  as  these  cir- 
cumstances favour  exposure  to  the  known  exciting  causes  of 
the  disease  or  diminish  the  resisting  power  of  the  individual. 

During  the  first  dentition  some  children  have  repeated 
attacks  of  bronchial  catarrh  coincident  with  the  eruption  of 
each  tooth,  just  as  other  children  suffer  from  catarrh  of  the 
nasal  or  intestinal  tract,  and  from  the  time  of  dentition 
onwards  throughout  childhood  bronchitis  is  common.  This 
is  to  be  accounted  for  partly  on  grounds  of  lessened  power 
of  resistance,  partly  in  consequence  of  dentition  itself,  and  in 
part  also   from   the   frequently   impaired   nasal   development 

*  The  statistics  of  Mr.  Campbell  Bayard'  show  that  at  nearly  all  the 
English  stations  the  mean  temperature,  as  also  the  mean  minimum  tempera- 
ture, reaches  its  lowest  in  January,  and  the  mean  relative  humidity  its 
maximum. 

176 


BRONCHITIS — BRONCHIAL   CATARRH  1/7 

and  obstructed  nasal  passages  of  children,  which  necessitate 
oral  breathing.  Adenoid  growths  in  the  posterior  nares  are 
the  most  common  cause  of  such  obstruction  in  both  sexes,  and 
are  especially  prevalent  in  the  Jewish  race.  The  abnormal 
method  of  breathing  thus  entailed  not  infrequently  remains 
a  bad  habit  through  life,  and  is  a  fertile  source  of  chest 
troubles  by  the  direct  manner  in  which  the  air  is  permitted  to 
enter  the  bronchi  and  lungs,  unwarmed  and  unfiltered  by  its 
passage  through  the  nares. 

Old  people  have  but  feeble  powers  of  resistance,  and  bron- 
chitis is  very  prevalent  and  fatal  amongst  them.  The  male  sex 
is  more  exposed  to  the  causes  which  lead  to  bronchitis  than 
the  female,  and  suffers  more  accordingly. 

Cachexia  of  various  kinds,  gout,  syphilis,  phthisis,  alco- 
holism, or  Bright's  disease,  must  also  be  ranked  amongst  the 
predisposing  causes  of  the  disease,  one  or  other  of  these 
maladies  being  often  at  the  root  of  the  more  protracted  and 
recurrent  cases.  Certain  forms  of  heart  disease,  such  as 
mitral  regurgitation  and,  in  a  still  greater  degree,  mitral 
stenosis,  also  predispose  to  bronchitis  by  obstructing  the 
return  of  blood  from  the  lungs,  thus  causing  mechanical  con- 
gestion of  these  organs  and  of  the  smaller  bronchi. 

Heredity  has  a  certain  influence  in  the  causation  of  the 
disease.     Recurrent  bronchial  catarrh,  associated  with  asth- 
matic symptoms,  and  with  more  or  less  emphysema,  is  well 
known  to  be  an  hereditary  affection,  and  may  occur  very 
early  in  life.     The  winter  bronchitis  to  which  many  individuals 
become  subject  at  certain  periods  of  life  also  runs  markedly 
in  families,  and  is,  no  doubt,  really  a  phenomenon  of  prema- 
ture senility.     But,  with  these  exceptions,  it  cannot  be  said 
that  bronchitis  is  hereditary,  and  our  own  observations  would 
lead  us  to  the  opinion  that,  when  the  predisposition  is  appar- 
ently seen  running  through  the  children  of  certain  famihes, 
it  is  often  connected  rather  with  enlarged  tonsils  or  imper- 
fect development  and  adenoid  affections  of  the  nasal  passages, 
which   necessitate   oral   breathing,   than   with   any   inherited 
delicacy  of  the  bronchial  membrane. 

Of  all  the  exciting  causes  of  bronchitis,  depression  of  tem- 
perature is  the  most  important.  The  attack  commonly  super- 
venes upon  exposure  to  sudden  changes  of  temperature  or 
to  cold,  wet  winds,  especially  in  depressed  conditions  of  the 

12 


1/8  DISEASES   OF  THE  LUNGS   AND  PLEURA 

system,  when  the  patient  has  been  overheated  by  exertion  or 
exhausted  by  mental  fatigue  or  shock.  A  draught  of  cold 
air,  affecting  a  very  limited  portion  of  the  body,  or  the  chilling 
of  the  feet  from  sitting'  in  wet  boots  may  be  sufficient  to  pro- 
duce it.  Bronchial  attacks  frequently  begin  with  "  colds  in 
the  head,"  and  many  people  have  a  morbid  state  of  the  naso- 
pharyngeal membrane,  which  tends  to  the  production  of  stag- 
nant and  unhealthy  mucus,  harbouring-  the  germs  of  catarrhal 
and  influenzal  diseases.  This  is  an  important  point  to 
remember  in  the  treatment,  or  rather  the  prevention,  of  recur- 
rent bronchial  catarrh. 

Another  factor  of  great  importance  in  the  causation  of  the 
disease  is  the  inhalation  of  irritating  particles,  and  certain 
occupations  which  are  very  dusty  prove  harmful  in  this 
respect.  These  trades  have  been  divided  by  Hirt'  into  five 
classes,  according  as  the  dust  is  (i)  metalHc  (as  with  file- 
cutters  and  knife-grinders);  (2)  mineral  (as  with  potters, 
masons,  and  cement-workers);  (3)  vegetable  (as  with  coal- 
miners,  tea-packers,  fret-cutters,  and  fiax-dressers);  (4)  animal 
fas  with  wool-carders  and  furriers);  and  (5)  mixed  (as  with 
street-sweepers)— an  interesting  classification,  in  that  it  indi- 
cates how  various  are  the  kinds  of  dust  which  may  be  at  fault 
and  how  numerous  are  the  occupations  affected.  In  a  later 
chapter  (Chapter  XV.)  we  shall  describe  a  case  of  dust  bron- 
chitis and  asthma  produced  by  the  inhalation  of  rosewood  dust. 
It  is  instructive  to  note,  however,  that  of  those  who  are  exposed 
to  irritating  mechanical  influences  of  this  kind  many  escape 
unharmed;  and  Hirt  has  further  observed  that  among  those  at 
first  attacked  the  inhalation,  if  continued,  may  after  a  time  fail 
to  excite  catarrh,  the  workmen  becoming,  as  it  were,  acclima- 
tised to  their  conditions.  On  the  other  hand,  in  noting  the 
history  of  patients  who  have  suffered  from  irritative  bron- 
chitis, we  have  found  instances  in  which  the  fathers  of  the 
patients  had  passed  their  lives  at  the  same  occupation  with- 
out complaint,  the  second  or  third  generation  thus  seeming 
m  some  cases  to  become  more  vulnerable  to  the  given 
influences. 

But  the  evil  effect  of  dust  is  not  Hmited  to  certain  occupa- 
tions. Many  a  fresh  catarrh  in  cases  of  confirmed  pulmonary 
disease  may  be  traced  to  dusty  winds  or  to  the  irritating 
fogs,  which  so  frequently  prevail  in  London  and  its  neio-h- 


BRONCHITIS— BRONCHIAL   CATARRH  179 

boiirhood,  and  which  prove  so  deadly  a  scourge  to  elderly 
bronchitic  subjects. 

Bronchitis,  again,  is  closely  connected  with  many  of  the 
specific  fevers.  Thus,  measles,  whooping-cough,  typhoid 
fever,  and  smallpox  are  attended  by  it  usually  in  the  early 
periods  of  the  disease.  Bronchial  catarrh,  sometimes  of  a 
very  obstinate  character,  and  yielding  only  to  specific  treat- 
ment, is  a  not  infrequent  concomitant  of  the  eruptive  period 
of  syphilis;  and  in  influenza  acute  bronchitis  often  forms  an 
important  element  in  the  disease. 

Blood  mingled  with  septic  matter  inhaled  into  the  bronchial 
tubes  during  an  attack  of  haemoptysis  or  during  tracheotomy 
may  set  up  bronchitis,  and  a  virulent  form,  attended  with 
profuse  expectoration,  is  occasioned  by  the  passage  over 
the  bronchial  surface  of  acrid  septic  matters  from  foetid 
pulmonary  or  pleural  cavities.  Bronchitis  and  broncho-pneu- 
monia are  also  well  known  and  sometimes  fatal  complications 
of  surgical  operations,  the  irritating  effects  of  certain  anaes- 
thetic vapours,  such  as  ether,  upon  the  bronchial  mucous 
membrane,  and  the  aspiration  of  saliva  into  the  air  passages 
during  the  administration  of  the  anaesthetic,  especially  when 
this  is  accompanied  by  much  struggling  and  cyanosis,  being 
probably  the  determining  factors.^ 

Bacteriology. — In  the  preceding  paragraphs  we  have 
enumerated  the  more  important  factors  concerned  in  the  pro- 
duction of  bronchitis.  It  must  be  clearly  understood,  how- 
ever, that  for  the  most  part  these  are  but  predisposing-  causes 
which,  by  their  weakening  influence,  favour  the  growth  of 
micro-organisms  which  play  a  preponderating  role  in  the 
development  of  the  disease. 

Of  the  organisms  which  may  be  at  fault,  the  pneumococcus 
and  the  streptococcus  are  the  most  important;  but  Pfeiffer's 
bacillus  of  influenza  and  the  micrococcus  catarrhalis  are  not 
infrequently  present,  and  no  doubt  take  their  share  in  the 
aetiology  of  the  disease.  Occasionally  other  organisms  are 
found  in  the  bronchial  secretion,  such  as  the  staphylococcus 
aureus  and  albus,  the  bacillus  pyocyaneus,  or  the  diphtheria 
bacillus,  the  latter  even  in  the  absence  of  any  clinical  evidence 
of  diphtheria.  In  certain  cases  one  or  other  of  the  micro- 
organisms mentioned  may  be  found  in  pure  culture  in  the 
bronchial  exudation  and  must  then  be  held  responsible  for 


l80  DISEASES   OF   THE   LUNGS   AND   PLEUR.E 

the  attack;  but  in  the  majority  of  cases  this  is  not  so,  and  the 
bronchitis— at  all  events,  in  its  later  stages— results  from  a 
mixed  infection  by  two  or  more  organisms,  among  which  the 
pneumococcus,  streptococcus,  Pfeiffer's  bacillus,  and  micro- 
coccus catarrhalis  figure  most  prominently. 

In  tropical  climates,  as  shown  by  Castellani*  and  others, 
bronchitis  is  sometimes  produced  by  a  spirochsete  {Broncho- 
spiro.chcetosis),  the  organism  Being  found  in  large  numbers 
in  the  sputum.  It  would  appear  probable  also  that  in  these 
climates  bronchial  catarrh  is  not  uncommonly  due  to  the 
presence  in  the  air  passages  of  hyphomycetes  and  other  fungi 
(Broncho-mycosis).^  The  so-called  "tea-factory  cough,"  com- 
mon in  Ceylon,  is  probably  an  affection  of  this  nature. 

Morbid  Anatomy. — The  characteristic  appearances  of  acute 
catarrh  are  but  rarely  to  be  observed  post-mortem,  but  they 
may  sometimes  be  seen  in  perfection  in  the  trachea  during 
life  by  means  of  the  laryngoscope. 

1.  In  the  first  stage  there  is  hypersemia  of  the  mucous 
membrane,  with  oedema  of  the  basement  layer.  The  affected 
membrane  is  minutely  injected,  swollen,  and  unduly  lacerable, 
and  presents  in  severe  cases,  especially  in  young  children, 
minute  haemorrhages.  Upon  hypersemic  swelling  of  the 
mucous  follicles  depends  in  part  the  temporary  check  to 
secretion,  which  characterises  the  early  stages  of  bronchitis, 
the  ducts  of  the  follicles  being  also  to  some  extent  occluded 
by  the  swollen  condition  of  the  mucous  membrane  which  they 
traverse. 

2.  The  mucous  flow  is  soon  increased,  however,  and  is 
mingled  with  sanious  exudation  from  the  vessels,  sheddings 
of  columnar  epithelium,  cubical  or  small  round  cells  derived 
from  multiplication  of  the  deeper  cells  of  the  epithelial  layer, 
and  with  pus  cells.  Thus  is  constituted  the  muco-purulent 
secretion  of  bronchitis,  thin  and  glairy  at  first,  thicker  and 
more  opaque  after  a  few  days.  To  the  naked  eye  the  appear- 
ance of  the  mucous  membrane  is  now  more  slaty  in  hue, 
covered  with  secretion,  sanious  or  thick,  according  to  the 
stages  referred  to. 

3.  The  tissues  of  the  bronchial  tubes  beneath  the  basement 
membrane  do  not  remain  passive  whilst  these  active  processes 
are  going  on  in  the  layers  above  them.  As  demonstrated  by 
the    late    Professor    Hamilton,*    the    connective-tissite    cells 


BRONCHITIS — BRONCHIAL  CATARRH  l8l 

multiply,  and  the  endothelium  of  the  lymphatic  spaces  of  the 
inner  and  outer  fibrous  layer  proliferates.  The  products  of 
such  proliferation  do  not,  however,  find  their  way  to  the  sur- 
face, being  unable  to  penetrate  the  basement  membrane,  but 
collect  in  the  interstices  of  the  cellular  tissue,  and  fill  up  the 
lymph  paths  along  which  they  slowly  course  towards  the 
bronchial  glands.  By  these  processes  thickening  of  the 
bronchial  membrane  is  effected,  together  with  some  indura- 
tion of  lung  texture  spreading  from  the  bronchial  sheaths. 

Clinical  Varieties  of  Bronchitis. 

Like  many  other  diseases,  bronchitis  may  present  itself  in 
atii  acute  or  in  a  chronic  form;  and  these,  again,  may  appear 
under  various  disguises.  The  following  classification  em- 
braces the  chief  varieties  met  with  in  practice : 

1.  Acute  Bronchitis — (a)  Acute  tracheo-bronchitis  (affect- 
ing the  larger  and  medium-sized  tubes;  the  common  form  of 
the  disease  in  the  adult). 

(b)  Capillary  bronchitis,  or  suffocative  catarrh  (occurring 
mostly  in  children,  and  affecting  chiefly  the  smaller  tubes). 

(c)  Acute  asthenic  bronchitis  (occurring  at  the  extremes  of 
life,  but  especially  in  the  aged.  In  it  the  toxic  symptoms  are 
marked). 

(d)  Purulent  bronchitis — an  acute  variety  of  bronchitis, 
occurring  sometimes  in  epidemics,  and  marked  by  a  copious 
purulent  expectoration,  in  which  Pfeiffer's  bacillus  of  influenza 
is  often  found.  It  is  met  with,  however,  also  in  a  chronic 
form. 

2.  Chrcwic  Bronchitis— C/?ro«/c  muco-purulent  catarrh. 

3.  Peculiar  Forms  of  Bronchitis  (which  may  be  either 
acute  or  chronic). — 

(a)  Pituitoiis  catarrh,  or  bronchorrhoea  serosa. 

(b)  Bronchitis  sicca — dry  catarrh — catarrhe  sec. 

(c)  Elastic  bronchitis. 

Acute  Tracheo-Bronchitls. 

The  symptoms  which  usher  in  an  acute  catarrh  of  the  large 
bronchial  tubes--the  form  in  which  bronchitis  usually  mani- 
fests itself  i-n  the  adult— are  commonly  those  of  an  ordinary 
cold    in    the    head.      Chills    of    a    creeping    character,  never 


l82  DISEASES   OF  THE  LUNGS   AND  PLEUR.E 

amounting  to  a  rigor,  occur  from  time  to  time  on  the  first 
day,  and  are  attended  with  a  feehng  of  malaise,  a  somewhat 
hurried  pulse,  slight  soreness  of  the  throat,  sneezing,  and 
coryza.  The  temperature  is  raised  a  degree  or  so  above  the 
normal,  but,  although  there  is  thirst,  aching,  perhaps  pains  in 
the  limbs,  and  a  considerable  sense  of  feverishness,  the  febrile 
phenomena  are  really  very  slight  in  adults,  though  more 
decided  when  the  disease  occurs  in  young  children.  After 
some  twenty-four  or  forty-eight  hours,  the  patient  complains 
of  a  soreness,  or,  as  it  is  often  more  accurately  described,  a 
rawness  behind  the  upper  sternum,  accompanied  by  a  sense 
of  constriction  or  oppression  in  this  region.  The  cough  is 
frequent  and  dry,  and  is  attended  with  more  or  less  pain  of  a 
rending  character.  The  voice  is  deepened,  and  sometimes 
husky  or  suppressed,  and  the  breathing  is  perceptibly  quick- 
ened. On  the  second  or  third  day  secretion  takes  place,  and 
with  the  expectoration  of  a  thin  aerated  mucus  the  patient 
soon  experiences  a  marked  sense  of  relief.  In  fact,  the 
pyrexial  stage  has  already  passed,  the  pulse  is  quiet,  the 
cough  loose,  and  expectoration  easy,  the  mucus  expelled 
becoming  more  opaque  and  semipurulent.  Gradually  the 
secretion  subsides  and  the  cough  lessens,  until  in  a  week  or 
ten  days  it  disappears,  except  that  in  the  morning,  on  first 
awaking,  the  patient  still  feels  some  oppression  in  the  chest, 
which  is  not  relieved  until  he  has  brought  up  some  purulent 
mucus. 

As  regards  physical  signs,  we  may  hear  a  few  dry,  sonorous 
rhonchi  vibrating  through  the  chest,  obviously  produced  in 
the  larger  tubes;  but  in  some  cases,  when  these  tubes  alone 
are  affected,  there  may  be  a  total  absence  of  all  physical  signs. 
When  the  secretion  is  more  established,  the  rhonchi,  which 
are  symmetrically  distributed  over  both  lungs,  become  looser, 
modified  or,  for  the  moment,  removed  by  cough,  and  accom- 
panied, especially  over  the  base  of  the  lungs,  by  scattered, 
muffled,  bubbling  rales.  The  percussion  note  over  the  chest 
is  unaltered. 

Capillary  Bronchitis,  or  Sufifocative  Catarrh. 

This  form  of  the  disease  may  be  met  with  at  all  ages,  but  is 
most  frequently  seen  in  children.  In  them  the  power  of 
coughing  is  at  a  minimum,  and  the  septic  secretion  of  the 


BRONCHITIS — BRONCHIAL  CATARRH  1 83 

larger  bronchi,  in  which  the  disease  begins,  finds  its  way 
rapidly  through  deep  inspiratory  efforts  or  by  gravitation 
into  the  finer  tubes.  These  quickly  become  blocked,  and  the 
characteristic  signs  of  the  disease,  merging  insensibly  into 
those  of  broncho-pneumonia,  become  developed.  Thus 
dyspnoea  soon  becomes  marked,  the  nares  expand  with  each 
inspiration,  the  lips  are  cyanosed  or  even  livid,  and  the  face 
assumes  an  anxious  and  distressed  expression.  The  tem- 
perature usually  reaches  101°  or  102°,  although  in  feeble  or 
old  people  there  may  be  considerable  systemic  shock,  with 
general  prostration  and  reduced  temperature.  The  pulse- 
rate  is  increased,  but  not  in  proportion  to  the  respiration. 
The  cough  is  frequent,  and  is  very  soon  accompanied  by  the 
expectoration  of  a  viscid  adhesive  mucus  difficult  to  dislodge. 
The  digestive  functions  are  impaired,  the  tongue  furred,  the 
bowels  confined,  and  the  urine  often  loaded  with  lithates. 

On  inspecting  the  chest,  the  thoracic  movements  are 
observed  to  be  increased,  since  it  is  mainly  with  the  com- 
paratively unaffected  front  and  upper  portions  of  the  lungs 
that  the  patient  breathes.  The  resonance  on  percussion  is 
everywhere  unimpaired,  and  it  may  be  even  increased.  Fine 
bubbling  rales  are  audible  over  both  posterior  bases,  and  to 
a  much  less  extent,  or  not  at  all,  over  the  upper  and  anterior 
portions  of  the  chest,  where,  however,  sibilant  and  sonorous 
sounds  prevail.  This  distribution  of  the  rales  in  bronchitis  is 
mainly  a  question  of  gravitation,  and,  as  the  late  Dr.  Walshe 
pointed  out,  even  in  bronchitis  of  mild  type,  and  not  involving 
to  any  extent  the  capillary  tubes,  we  may  still  hear  fine  rales 
at  the  posterior  bases  from  gravitation  of  the  secretion  to 
the  smaller  tubes.  After  a  few  days,  if  the  patient  have 
sufficient  strength,  the  signs  of  the  disease  gradually  lessen, 
and  convalescence  in  due  time  becomes  established;  but  the 
bronchi  long  remain  weakened  and  liable  to  a  fresh  attack, 
unless  carefully  shielded  from  exposure.  In  severe  cases, 
after  struggling  for  some  days,  the  signs  of  cyanosis  and 
asphyxia  increase,  the  patient  passes  into  a  drowsy  condi- 
tion, and  death  soon  follows. 

The  diagnosis  of  bronchitis  of  this  degree  depends  upon 
the  symmetrical  distribution  of  fine  bubbling  rales  not  asso- 
ciated with  any  percussion  dulness  or  bronchial  quality  of 
breath-sound,  and  with  but  a  moderate  rise  of  temperature. 


1 84  DISEASES   OF  THE  LUNGS   AND  PLEURA 

The  diseases  which  may  be  confounded  with  it  are  pulmonary 
cedema,  miliary  tuberculosis  of  the  lungs,  and  acute  phthisis. 

If  oedema  be  limited  to  the  lungs  it  must  be  dependent  upon 
cardiac  defect,  the  history  and  signs  of  which  render  the 
case  clear. 

Miliary  tuberculosis,  on  the  contrary,  may  be  easily  mis- 
taken for  bronchitis,  since  the  physical  signs  are  almost 
identical.  Nevertheless,  careful  examination  will  put  us  on 
our  guard.  Thus,  it  is  not  uncommon  in  tuberculosis  to  find 
that,  though  the  lungs  are  stuffed  with  miliary  tubercles, 
there  may  be  comparatively  few  moist  sounds,  and  these  often 
quite  as  marked  at  the  apex  as  at  the  base.  If,  therefore,  in 
a  given  case  we  find  excessive  dyspnoea,  cyanosis,  and  great 
prostration,  apparently  out  of  all  proportion  to  the  physical 
signs,  the  suspicion  of  miliary  tuberculosis  of  the  lungs 
should  at  once  suggest  itself.  The  temperature  is  not  dis- 
tinctive, since  in  tuberculous  cases  it  is  by  no  means  neces- 
sarily high.  Evidence  of  previous  pulmonary  disease  at  one 
apex  would  cause  the  diagnosis  to  lean  strongly  towards 
tuberculosis. 

In  children  especially,  acute  phthisis  of  the  caseous  broncho- 
pneumonic  type  may  lead  to  difficulty  in  diagnosis.  This 
variety  of  the  disease  not  infrequently  follows  whooping- 
cough  or  measles,  and,  from  the  diffuse  signs  of  bronchitis  to 
which  it  gives  rise,  may  for  a  time  be  confounded  with 
simple  catarrh.  Later,  more  or  less  pneumonic  crepitation, 
patchy,  tubular  breathing  and  larger  clicks,  are  superadded 
to  the  simple  rales,  and  the  signs  become  distinctly  more 
advanced  at  some  one  portion  of  the  chest,  whether  base  or 
apex.  But  here  again  the  diagnosis  between  a  simple  bron- 
chitis passing  on  into  broncho-pneumonia  and  the  tuber- 
culous variety  of  the  disease  is  by  no  means  easy.  The 
history  of  the  onset  after  measles  or  whooping-cough,  the 
longer  duration  of  the  disease,  and  its  steadily  downward 
course,  should  suggest  its  tuberculous  nature.  A  bacterio- 
logical examination  of  any  sputum  that  can  be  obtained  or 
of  the  fseces  should  by  no  means  be  neglected. 

Acute  Asthenic  Bronchitis. 

This  is  a  malady  commonly  met  with  at  both  extremes  of 
life,  and  in  the  aged  especially  it  is  one  of  the  most  fatal  of 


BRONCHITIS — BRONCHIAL  CATARRH  1 85 

diseases.  It  is  marked  chiefly  by  the  rapidity  of  its  course 
and  the  severity  of  its  toxic  symptoms.  The  following  fairly 
characteristic  example  may  be  related  in  illustration  of  the 
salient  features  of  the  disease :' 

Mrs.  M — '■ — ,  a  widow,  aged  seventy-six,  of  thin,  spare  build,  and 
of  previous  good  liealth,  was  dining  out  with  friends  on  the  evening 
of  December  27,  feeling  in  her  usual  good  health  and  spirits.  She 
had  never  before  suffered  from  any  chest  illness,  but  it  was  believed 

that  on  her  way  home  she  became  chilled.     Mrs.    M ,   however, 

appeared  well  the  next  morning,  but  towards  the  latter  part  of  the 
day  (28th)  felt  drowsy  and  somewhat  chilly.  She  became  more 
obviously  ill  in  the  course  of  the  evening,  the  breathing  being 
quickened  and  oppressed,  and  towards  midnight  her  symptoms  became 
so  aggravated  that  the  doctor  was  sent  for.  She  was  now  found  to 
be  in  a  state  of  profound  collapse,  with  small,  feeble  pulse,  cold 
extremities,  low  temperature,  and  sweating  surface.  The  respirations 
were  quick  and  shallow,  the  countenance  anxious,  and  the  mucous 
membranes  somewhat  cyanosed.  No  morbid  sounds  save  a  few 
wheezing  rhonchi  were  to  be  heard  over  the  chest. 

A  free  recourse  to  brandy  and  other  stimulating  remedies  rallied 
the  patient  so  notably  that  the  friends  became  hopeful,  and  the 
doctor  plied  his  remedies  and  planned  out  food,  physic,  and  stimu- 
lants with  a  cheery  exactness.  By  the  following  evening  the  chest 
signs  had  become  more  marked,  short  inspirations  being  followed 
by  prolonged  wheezing  expirations,  the  pulse  keeping  steady  at 
about  90  beats  a  minute.  The  cough  and  expectoration  were  now 
troublesome  and  difficult,  preventing,  as  the  night  advanced,  more 
than  brief  snatches  of  sleep.  The  body  temperature  rose  to  about 
100°,  and  it  was  observed  that  the  patient  wandered  in  slight  delirium, 
from  which,  however,  she  could  readily  rouse  herself.  Fine  bubbling 
rales  were  now,  at  the  close  of  the  second  or  third  day,  audible  over 
the  chest,  most  abundantly  and  most  definitely  at  the  posterior  bases, 
where  but  very  little  air  could  be  heard  to  penetrate.  The  respiratory 
movements  were  peculiar,  at  each  inspiration  the  chest  being  lifted 
quickly  by  the  action  of  the  auxiliary  muscles,  whilst  the  bases  of 
the  thorax  receded.  A  long  wheezing  expiration  followed  each  inspira- 
tion, apparently  produced  by  the  downward  recoil  of  the  chest  upon 
the  diaphragm,  which  had  been  pushed  upwards  to  meet  it  by  the 
contraction  of  the  abdominal  muscles. 

Tracheal  rattles  soon  became  developed,  removable  at  first  by  cough, 
but  soon  to  return.  The  pulse  quickened,  the  patient  became  more 
exhausted,  with  muttering  delirium  or  incoherence,  and  death  closed 
the  scene  at  about  the  seventieth  hour. 

Such  is  a  sketch  of  the  phenomena  presented  by  a  case  of 
this  fatal  malady,  the  characteristic  features  being:  (i)  the 
almost  fatal  collapse  at  about  the  twelfth  hour  from  the  first 


1 86  DISEASES   OF  THE  LUNGS   AND  PLEUR.E 

shock  of  the  disease;  (2)  the  rallying  of  the  patient,  and  the 
oncoming  of  the  signs  of  general  bronchitis,  attended  with 
slight  febrile  reaction;  (3)  at  about  the  third  day  the  appear- 
ance of  laboured,  ineffectual  breathing,  with  signs  of  filhng 
of  the  lower  bronchi,  indicative,  no  doubt,  of  exhaustion  of 
the  nerve  centres.  The  forcible  respiratory  efforts,  far 
beyond  the  strength  of  the  patient,  which  appear  at  this  last 
and  fatal  stage,  and  continue  to  the  end,  are  very  noticeable, 
and  it  is  rare  indeed  for  recovery  to  ensue  in  any  case  in 
which  this  character  of  breathing  has  once  been  observed. 

But  such  grave  forms  of  the  disease  are  not  limited  to  the 
aged,  for  young  children  not  infrequently  succumb  to  the 
first  shock  of  bronchitis,  being  overwhelmed  before  their 
illness  seriously  attracts  the  attention  of  their  parents.  A 
considerable  proportion  of  the  infants  brought  to  our  hos- 
pitals dead,  or  in  a  dying  condition  from  sudden  illness,  are 
found  post-mortem  to  present  no  other  lesions  beyond  the 
signs,  very  slightly  marked,  of  early  bronchitis.  A  few 
petechial  spots  in  the  mediastinum,  pericardium,  or  pleura, 
may  testify  to  the  brief  struggle  of  the  little  patients. 

Purulent  Bronchitis. 

Attention  has  recently  been  drawn  to  a  form  of  acute 
bronchitis,  which  has  occurred  in  epidemic  form  among  our 
troops  both  in  France''  and  in  England,^  and  which  is  char- 
acterised by  the  expectoration  of  abundant  nummular  sputa 
composed  almost  entirely  of  pus.  The  amount  may  reach  as 
much  as  fifteen  ounces  in  the  twenty-four  hours. 

These  cases,  first  described  by  Drs.  Hammond,  Rolland, 
and  Shore,'  are  sometimes  very  acute,  and  for  a  time  sug- 
gest pneumonia;  but  the  sputum,  never  really  rusty,  soon 
acquires  its  characteristic  appearance.  Tachycardia,  dyspnoea, 
and  cyanosis,  often  of  a  "heliotrope"  tint,  are  prominent 
symptoms,  and  the  patient  not  uncommonly  dies  in  about  a 
week  from  cardiac  failure,  the  smaller  bronchi  and  bronchioles 
being  found  after  death  to  be  filled  with  purulent  exudation. 
In  other  cases,  less  acute,  the  malady  may  last  some  weeks, 
the  temperature  varying  from  101°  to  103°,  and  here  again 
cyanosis  and  respiratory  distress  are  marked  features.  In 
the  early  stages  moist  sounds  are  heard  scattered  over  the 
lungs,  to  be  succeeded  later  by  signs  of  broncho-pneumonia. 


BRONCHITIS — BRONCHIAL   CATARRH  1 8/ 

In  such  cases  the  patient  wastes  and  often  sweats,  and  the 
disease  maybe  mistaken  for  acute  tuberculosis.  The  mortahty 
in  the  epidemics  which  we  have  been  describing  has  been 
severe,  but  of  the  less  acute  cases  many  recover. 

Bacteriologically  the  cases  are  of  interest,  for  in  the 
majority  the  Pfeiffer's  bacillus  of  influenza  has  been  found 
in  the  sputum,  associated  in  many  instances  with  the  pneu- 
mococcus.  In  an  epidemic  occurring  among  a  draft  of 
troops  from  New  Zealand,"  in  which  the  purulent  bronchitis 
occurred  as  a  complication  of  measles  and  rubella,  Pfeiffer's 
bacillus  and  the  streptococcus  were  the  organisms  most  often 
present.  In  view,  however,  of  the  evidence  recently  brought 
forward  by  Sir  John  Rose  Bradford  and  Drs.  Bashford  and 
Wilson,'"  suggesting  that  a  filter-passing  virus  may  be  the 
cause  of  influenza,  the  presence  of  the  Pfeiffer's  bacillus  can- 
not be  held  as  proof  that  these  cases  of  purulent  bronchitis  are 
truly  influenzal  in  nature. 

It  must  not  be  supposed,  moreover,  that  "purulent  bron- 
chitis "  is  met  with  only  in  epidemics,  though  these  have 
naturally  directed  especial  attention  to  its  occurrence.  We 
have  met  with  more  than  one  instance  of  subacute  bronchitis 
in  which  the  sputum  has  had  this  special  character,  though 
the  amount  expectorated  has  not  reached  the  large  quantity 
recently  described,  and  in  which  the  pneumococcus  was  pre- 
sent in  pure  culture.  We  know  also  of  the  case  of  a  gentle- 
man, aged  between  eighty  and  ninety,  who  during  the  few 
years  preceding  his  death  had  several  attacks  of  subacute 
bronchitis,  each  accompanied  by  the  expectoration  of  char- 
acteristic purulent  sputum,  which  continued  also  between  the 
attacks.  On  two  occasions  this  was  found  to  contain  a  pure 
culture  of  Pfeiffer's  bacillus.  Lastly,  as  we  shall  see,  copious 
purulent  expectoration  is  sometimes  associated  with  the  later 
stages  of  a  chronic  muco-purulent  catarrh,  and  to  this  condi- 
tion the  terms  purulent  bronchitis  or  broncho-blennorrhoea 
have  long  been  applied  (see  p.  191). 

Prognosis  in  Acute  Bronchitis. — From  what  we  have 
already  said  it  will  be  understood  that  the  outlook  in  acute 
bronchitis  of  whatever  degree,  when  occurring  in  adults,  is, 
generally  speaking,  favourable.  Capillary  bronchitis  in  very 
old  and  very  young  people,  and  still  more  so  the  acute 
asthenic  and  "purulent"  forms,  are,  on  the  other  hand,  fre- 


t88  diseases  of  the  lungs  and  pleura 

quently  fatal.     Nevertheless,  there  is,  perhaps,  no  disease  the 
mortality  of  which  is  more  influenced  by  treatment. 

Treatment. — Taking  capillary  bronchitis  in  the  adult  as  our 
text  in  regard  to  treatment,  our  first  thought  should  be  to 
see  that  the  room  is  adequately  warmed.  For  this  purpose  a 
fire  and  steam-kettle  are  necessary,  so  as  to  raise  the  tempera- 
ture of  the  room  to  about  62°,  and  immense  relief  is  given 
to  the  patient  by  this  means  alone.  Due  care  must  be  taken, 
however,  to  insure  a  proper  and  constant  supply  of  fresh  air, 
as  well  as  to  preserve  a  uniform  temperature.  The  use  of 
the  steam-kettle  is  not  only  to  moisten  the  air  of  the  room — 
itself  a  point  of  no  small  importance  when  the  cough  is 
irritable  and  the  expectoration  viscid — but  because  in  most 
bedrooms  it  is  the  only  possible  means  of  raising  the  tempera- 
ture and  maintaining  it  during  cold  weather  at  the  desired 
height. 

A  large  mustard  or  mustard  and  linseed  poultice  should  be 
applied  to  the  front  of  the  chest  or  to  the  back,  and  followed 
up  by  hot  hnseed  applications  or  cotton-wool  to  the  chest. 
In  children  a  jacket  poultice  is  often  very  useful,  but  one 
must  not  forget  that,  both  in  young  or  weakly  children  and 
in  old  people,  a  linseed  poultice  wrapped  round  the  chest  may 
be  a  very  serious  impediment  to  free  thoracic  movements,  and 
in  such  cases  it  is  often  more  judicious  to  have  recourse  to 
cotton-wool  covered  with  oil-silk  and  an  occasional  mustard 
or  mustard  and  linseed  pouUice  to  keep  the  blood  determined 
to  the  surface.  Pouhices  are  indeed  valuable  in  the  hands  of 
the  careful  and  skilled  attendant;  otherwise,  hot  cotton-wool 
applications,  with  the  occasional  help  of  a  stimulating  poul- 
tice, are  much  to  be  preferred.  Pine  or  thermogen  wool  are 
more  stimulating  than  ordinary  cotton-wool,  and  are  to  be 
recommended  especially  for  old  people.  Where  the  constant 
attention  of  a  skilled  nurse  is  not  possible,  antiphlogistine 
apphcations  are  especially  useful,  not  requiring  frequent 
renewal.  For  convenience,  and  to  save  fatigue  in  the  use  of 
poultices,  the  nightdress  should  be  cut  down  the  middle,  and 
brought  together  with  tapes  or  safety-pins. 

As  regards  drugs,  a  saline  mixture  with  ipecacuanha  is  the 
best  with  which  to  begin.  In  strong  aduhs  antimony  wine 
is  very  useful,  especially  in  the  early  dry  stage  of  the  catarrh, 
and   should  be  given  in   small   doses  at   frequent  intervals! 


BRONCHITIS — BRONCHIAL   CATARRH  1 89 

Apomorphine,  in  aV  to  yV  grain  doses,  is  often,  and  especially 
in  cases  where  there  is  some  degree  of  bronchial  spasm,  a 
valuable  substitute  for  ipecacuanha  or  antimony  in  the  pre- 
scription. In  old  people,  on  the  other  hand,  carbonate  of 
ammonia  is  generally  required.  The  special  danger  in  infants 
arises  from  the  possible  occurrence  of  pulmonary  collapse 
and  broncho-pneumonia.  These  are  due  to  the  inability  of 
children  to  expectorate,  and  the  consequent  plugging  of  the 
bronchi  with  secretions,  which  are  drawn  into  the  correspond- 
ing alveoli  during  vain  inspiratory  efforts.  The  timely 
administration  of  ipecacuanha  emetics,  if  the  secretion  be 
abundant,  will  in  some  cases  avert  this  danger.  Friction  with 
stimulating  liniments,  such  as  the  ammonia  or  acetic  turpen- 
tine liniments  of  the  Pharmacopoeia,  further  diluted,  if  neces- 
sary, with  an  equal  quantity  of  olive  oil,  is  of  great  service  in 
young  children  after  the  first  stage  has  passed. 

In  old  people  danger  arises  principally  from  exhaustion, 
with  atony  of  the  bronchial  tubes.  To  avert  these  dangers 
we  must  from  the  first  support  the  patient  by  the  frequent 
administration  of  nutritious  liquids  and  by  the  timely  employ  • 
ment  of  stimulants  in  carefully  regulated  doses.  Of  all 
alcoholic  stimulants,  brandy  is  certainly  the  best  for  this  pur- 
pose, though  we  have  at  times  found  whisky,  with  hot 
peppermint-water,  an  excellent  stimulating  expectorant.  The 
administration  of  opiate  remedies  in  bronchitis  should,  as  a 
rule,  be  avoided,  and  absolutely  so  in  cases  in  which  lividity 
of  lips  shows  already  defective  aeration  of  blood.  For  young 
children  and  old  people  opium  should  never  be  used  in  bron- 
chitis. As  a  sedative  at  night,  bromide  of  ammonium,  with 
aromatic  spirits  of  ammonia,  is  one  of  the  best  we  can  choose. 
Chloral  is  not  very  suitable  in  acute  cases,  but  a  small  dose 
combined  with  bromide  of  ammonium  will  sufifice  to  give  rest 
without  risk  of  unduly  depressing  the  heart's  action.  When 
there  is  much  lividity,  with  restless,  muttering  delirium, 
oxygen  inhalations  may  be  used  with  much  success,  securing 
short,  refreshing  sleeps,  and  maintaining  nerve  and  cardiac 
power.  When  the  heart  fails,  and  symptoms  of  overloading 
of  the  right  ventricle  present  themselves,  digitalis  may  be 
usefully  given,  stimulants  must  be  persevered  with,  and  dry- 
cupping  may  be  tried  with  advantage.  In  certain  cases  in 
which  there  is  marked  venous  plethora,  with  a  weak  and  fail- 


1 90  DISEASES   OF  THE  LUNGS   AND   PLEURA 

ing  heart's  action  from  an  overburdened  right  ventricle, 
venesection  is  attended  with  manifest  reHef. 

Next  to  avoiding  a  fatal  issue,  our  efforts  should  be  directed 
to  prevent  the  case  passing  into  the  chronic  stage,  which  is 
especially  to  be  feared  in  those  who  have  suffered  from 
previous  attacks.  When  the  acute  symptoms  are  past,  some 
patients  at  once  convalesce  without  any  special  treatment; 
in  others  the  secretion  continues  abundant  and  purulent.  In 
such  cases  the  saline  mixture  must  be  given  less  frequently 
or  changed  for  a  more  stimulating  expectorant  containing 
senega  and  ammonia ;  and  a  mixture  containing  some  mineral 
acid,  with  calumba  or  quinine,  may  be  taken  twice  a  day. 
The  turpentine  acetic  liniment  is  of  great  value  in  this  stage, 
its  usefulness  being  probably  in  part  due  to  inhalation  of  the 
turpentine  vapour.  Meanwhile  the  bodily  strength  must  be 
well  maintained,  and  for  this  purpose  cod-liver  oil  may  be 
prescribed. 

In  cases  in  which  there  is  a  tendency  to  frequent  catarrh 
the  naso-pharynx  should  be  looked  to,  and  will  often  be  found 
to  be  in  a  catarrhal  condition  and  to  lodge  unhealthy  muco- 
pus,  which  may  be  sometimes  observed  in  the  posterior  naso- 
pharynx. We  are  in  the  habit  of  advising  in  such  cases  the 
use  of  a  lotion  consisting  of  chloride  of  sodium  oi.,  salicylate 
of  soda3i.,  or  borate  of  sodium  3i.ss.,  hazeline  3iii.,  glycerine 
5iii.,  and  rose-water  to  §viii. :  one  tablespoonful  to  a  wineglass 
of  warm  water  for  a  nasal  douche :  or  a  choice  can  be  made 
from  the  various  collunaria  of  the  London  hospitals." 

Chronic  Bronchitis — Chronic  Muco-Purulent  Catarrh. 

This  is  met  with  most  frequently  in  elderly  people,  but  it  is 
by  no  means  unknown  in  adult  life,  and  occurs  not  very 
rarely  even  in  children  whose  nutrition  is  markedly  impaired. 
It  may  sometimes  originate  in  an  acute  attack  from  which 
recovery  has  been  incomplete,  and  may  in  this  way  be  traced 
back  to  measles  or  whooping-cough,  from  which  the  patient 
suffered  several  years  before.  Many  cases  in  the  adult,  how- 
ever, cannot  be  traced  to  a  primary  acute  attack,  and  the 
disease  is  then  chronic  from  the  commencement.  This  may 
be  observed  in  patients  who  are  otherwise  healthy,  but  in 
some  the  disease  is  associated  with  a  constitutional  malady, 
such   as    gout    or   chronic   nephritis.      In   not    a    few    cases 


BRONCHITIS — BRONCHIAL   CATARRH  IQI 

alcoholism  is  the  true  factor  in  causation.  In  others,  exces- 
sive smoking-  and  inhaling-  or  a  dusty  occupation  are  respon- 
sible for  the  continuance  of  the  malady. 

Cough  and  the  expectoration  of  muco-purulent  sputum, 
with  possibly  some  dyspnoea  on  exertion,  though  the  latter 
depends  upon  the  resulting  emphysema  rather  than  upon 
the  bronchitis  itself,  are  the  principal  symptoms  of  which 
complaint  is  made.  These  are  always  more  marked  in  winter 
than  in  summer,  and  in  early  cases  they  disappear  entirely  as 
the  warmer  weather  comes  round. 

As  regards  physical  signs,  there  are  two  factors  responsible 
for  them — first,  the  bronchial  catarrh,  with  mucous  secretion 
causing-  the  breath-sounds  to  be  modified  by  rales  and 
rhonchi;  and,  secondly,  more  or  less  associated  emphysema 
of  the  lungs,  causing-  a  tendency  to  extension  of  pulmonary 
resonance  beyond  its  normal  limits  (see  Emphysema). 

At  first  the  patient  suffers  but  little  inconvenience  from  his 
complaint.  In  the  early  morning,  on  first  waking-,  he  may  be 
troubled  with  cough,  but  after  the  tubes  have  been  freed  from 
the  secretion  which  has  accumulated  during  sleep,  he  will 
remain  practically  undisturbed  for  the  remainder  of  the  day. 
But  with  the  progress  of  the  disease  his  hours  of  immunity 
become  lessened,  and  this  is  especially  the  case  whenever  the 
weather  is  damp,  cold,  and  foggy.  The  amount  of  cough 
will,  however,  vary  to  some  extent,  according  to  the  char- 
acter of  the  sputum.  Whenever  this  is  viscid  and  difficult  to 
expectorate,  the  cough  will  become  more  trying;  whenever 
it  becomes  more  loose,  the  symptoms  are  alleviated. 

The  sputum  in  a  typical  case  consists  of  mucus  mixed  with 
pus.  Sometimes  these  are  mingled  more  or  less  uniformly; 
in  other  cases  the  pus  predominates,  and  is  at  times  seen 
floating  in  separate  coin-hke  masses  in  the  mucus  and  saliva. 
Such  "  nummular  sputum  "  does  not  necessarily  indicate  the 
existence  of  bronchial  dilatation.  At  a  later  period  of  the 
disease  the  amount  of  sputum  may  be  greatly  increased,  and 
the  terms  "  purulent  bronchitis,"  and  "  broncho-blennorrhoea,"* 
have  been  employed  to  indicate  the  condition  (see  p.  187).  At 
other  times   the    expectoration   becomes    offensive.      In   the 


*  Blenna,  like  phlegma,  pituita,  and  mucus,  was,  as  the  late  Dr.  Gee'^" 
minded  us,  but  one  of  the  terms  used  haphazard  by  the  ancient  physicians 
to  signify  the  sputum,  whether  transparent  or  opaque. 


remin 


192  DISEASES    OF   THE   LUNGS   AND   PLEURA 

absence  of  bronchiectasis  this  symptom  rarely  lasts  for  more 
than  a  few  days  or  a  week,  and  then  gradually  passes  away. 
It  is  of  no  serious  import,  and  probably  results  from  the 
sputum  becoming  temporarily  more  viscid  than  usual,  leading 
to  its  retention  within  the  bronchi  sufficiently  long  for  putre- 
factive changes  to  set  in.  The  condition  of  the  mouth  and 
teeth  as  a  possible  source  of  the  fcetor  should  be  investi- 
gated. 

Of  the  existence  of  a  special  form  of  putrid  or  foetid  bron- 
chitis, in  which,  without  any  organic  lesion,  such  as  bron- 
chiectasis or  gangrene  of  the  bronchial  membrane,  the  secre- 
tion is  continuously  offensive,  we  do  not  feel  convinced.  A 
feculent  odour  is  stated,  however,  to  occur  sometimes  in  cases 
of  pulmonary  streptotrichosis. 

At  first,  as  we  have  said,  the  patient's  nights  are  but  little 
disturbed  by  his  complaint;  but  later,  as  the  secretion  becomes 
greater  in  amount,  attacks  of  dyspnoea,  which  closely  resemble 
the  paroxysms  of  true  asthma,  break  his  rest.  With  sleep 
thus  disturbed,  and  with  the  disease  making  gradual  pro- 
g'ress — now  slowly,  now  more  quickly — under  the  influence 
of  intercurrent  and  more  acute  attacks,  the  patient's  strength 
gradually  ebbs,  though  it  is  surprising  how  long  the  combat 
is  maintained.  At  length  the  fatal  issue  is  ushered  in  by  an 
exacerbation  of  the  disease,  or  by  gradual  failure  of  the  right 
side  of  the  heart  to  withstand  the  extra  strain  thrown  upon 
it  by  advancing  emphysema. 

Treatment. — In  cases  in  which  the  cough  is  dry  and  there 
is  difficulty  in  expectorating  the  phlegm,  relief  will  often  be 
given  by  a  mixture  containing  vinum  ipecacuanhse,  potassium 
bicarbonate,  and  potassium  iodide,  for  one  of  which,  in  cases 
requiring  stimulation,  we  may  substitute  ammonium  car- 
bonate. Chloride  of  ammonium  is  often  also  of  great  value. 
When,  on  the  other  hand,  there  is  much  muco-purulent  expec- 
toration, considerable  advantage  may  be  gained  by  the  use 
of  tar,  of  which  good  preparations  are  Guyot's  Eau  de 
Goudron  (oi.j  or  Bell's  Liquor  Picis  Aromaticus  (t1\xx.  to 
3i.),  in  plain  or  alkaline  water,  such  as  that  of  Vichy  or  Ems ; 
or  Jozeau's  capsules  may  be  preferred.  In  this  stage,  also, 
the  resinous  preparations,  such  as  oil  of  turpentine  and  tere- 
bene,  or  the  oil  of  sandal  wood,  are  sometimes  useful.  For 
the  paroxysms  of  asthma  iodide  of  potassium  and  stramonium 


BliOl>JCHITfS — BROisrCHIAL   CATARRH  1 93 

will  generally  prove  effective,  as  in  simple  asthma.  We  have 
not  been  greatly  impressed  with  the  value  of  vaccines  in  the 
treatment  of  chronic  bronchitis. 

But  in  many  cases  of  chronic  bronchitis  it  is  best  to  leave 
the  bronchial  membrane  alone,  and  to  direct  treatment 
towards  improving  dig"estion  and  appetite  and  the  general 
nutrition.  In  this  connection  we  must  emphasise  the  value 
of  cod-liver  oil,  which,  in  small  doses  of  one  or  two  teaspoon- 
fuls  three  times  a  day,  with  or  without  malt  extract,  we  have 
often  known  to  be  of  great  service.  With  the  cod-liver  oil,  if 
desired,  creosote  (Til v.  to  H^x.)  may  be  combined. 

The  above  are  at  best  but  palliative  measures,  which  assist 
the  patient  in  resisting  the  damp  and  fogs  so  associated  with 
our  climate,  and  to  which  the  malady  is  in  great  part  due. 
These  can  only  be  avoided  by  wintering  in  one  or  other  of 
our  brighter,  warmer,  and  more  sheltered  health  resorts,  or 
by  spending  the  season  abroad.  In  England  the  health 
resorts  upon  the  South  Coast  prove  most  beneficial,  and 
among  them  we  may  number  Penzance,  Falmouth,  Torquay, 
Sidmouth,  Lyme  Regis,  Bournemouth,  Ventnor,  and  Hastings, 
at  all  of  which  the  climate  is  suitable.  For  those  living 
in  the  Northern  and  Midland  counties,  Tenby,  Colwyn 
Bay,  and  Llandudno  may  be  recommended,  since  at  these 
places  the  winter  temperature  is  moderately  warm  and  abun- 
dance of  sunshine  is  experienced;  at  the  two  latter  places  the 
background  of  hills  affords  protection  from  the  northern 
winds  to  which,  from  their  geographical  position,  these 
stations  are  exposed.  Grange  and  Southport,  on  the  Lan- 
cashire seaboard,  are  also  suitable.  Of  the  inland  resorts, 
Malvern,  and  Bridge  of  Allan  are,  perhaps,  the  best  adapted  to 
the  treatment  of  the  disease. 

In  Ireland,  Rostrevor  on  Carlingford  Lough,  St.  Ann's, 
Blarney,  near  Cork,  or  Glengariff,  may  be  suggested.'^ 

Should  the  patient  be  sent  abroad,  one  or  other  of  the 
health  resorts  on  the  French  or  ItaHan  Riviera,  such  as 
Hyeres,  Cannes,  Nice,  Mentone,  or  San  Remo,  may  be  chosen. 
Of  places  farther  south,  Egypt  was  popular  before  the  war, 
and,  provided  the  patient  avoid  Cairo  and  stay  at  Mena 
House,  Helwan,  or  Assuan,  where  the  pure  desert  air,  with 
jits  stimulating  qualities,  brilliant  sunshine,  and  great  dryness, 
may  be  enjoyed,  no  better  selection  could  possibly  be  made 

13 


194  DISEASES   OF  THE  LUNGS   AND  PLEURA 

by  those  who  can  go  so  far.  But  whether  the  patient  winter 
in  Egypt  or  on  the  Riviera,  he  must  remember  that  in  neither 
case  will  it  be  wise  for  him  to  return  to  England  until  the 
beginning  of  May.  Otherwise,  the  biting  east  winds  of 
spring  will  not  be  avoided,  an  attack  of  acute  bronchitis  may 
follow,  and  all  the  benefit  derived  from  wintering  abroad  be 
nullified.  In  summer  a  course  of  treatment  at  Mont  Dore, 
or  if  the  patient  be  gouty,  at  Ems,  may  in  certain  cases  be 
taken  with  advantage. 

Peculiar  Forms  of  Bronchitis. 

The  varieties  of  bronchitis  were  classified  by  Laennec 
according  to  the  amount  and  character  of  the  expectoration. 
He  thus  recognised,  in  addition  to  the  ordinary  muco-purulent 
form,  a  type  in  which  the  secretion  was  peculiar  and  exces- 
sive, "  pituitous  catarrh,"  and  another,  in  which  the  expectora- 
tion was  very  scanty,  and  to  which  he  applied  the  name 
"  catarrhe  sec."  To  these  we  may  add  a  third,  the  so-called 
"plastic  bronchitis." 

I.  Pituitous  Catarrh.  (Bronchorrhoea  Serosa). — This  form 
of  bronchitis  was  first  described  by  Laennec.  "  Pituitous 
catarrh,"  he  wrote,^*"  "  is  a  catarrh  in  which  the  expectoration 
is  colourless,  transparent,  stringy,  frothy  on  the  surface,  and 
which,  when  the  foam  has  been  removed,  resembles  white  of 
egg  whipped  up  in  water."  Later  he  states  that  the  flux  is 
always  abundant.  To  this  description  we  may  add  that  the 
characteristic  sputum,  or  pituita,  is  non-albuminous,  thus  dis- 
tinguishing it  from  the  highly  albuminous  "  serous  expectora- 
tion," which  is  brought  up  in  cases  of  acute  oedema  of  the 
lung,  and  which  resembles  it  exactly  in  naked-eye  appear- 
ance (see  pp.  114  and  355). 

Pituitous  expectoration  occurs  sometimes  in  cases  of 
tuberculosis  of  the  lung,  whether  miliary  or  otherwise,  and  in 
certain  varieties  of  pulmonary  cancer.  In  the  cases  which  we 
are  now  considering  the  malady  is  a  primary  affection,  uncon- 
nected with  any  pre-existing  disease. 

Primary  pituitous  catarrh  may  be  acute  or  chronic,  although 
both  forms  of  the  disease  are  excessively  rare.  In  the  acute 
form  the  patient,  who  may  previously  have  been  in  perfect 
health,  is  suddenly  seized  with  great  oppression  of  the  chest 
and  cough,  and  dyspnoea  rapidly  ensues.     Large  quantities  of 


BRONCHITIS — BRONCHIAL   CATARRH  1 95 

colourless  frothy  sputum  (four  pints  in  one  instance  referred 
to  by  Laennec)  are  brought  up,  and  suffocation  may  be 
imminent,  or  may  actually  occur.  More  commonly,  after 
some  hours  of  intense  distress,  the  symptoms  gradually  abate, 
and  the  patient  recovers,  though  he  remains  liable  to  a  second 
attack,  possibly  some  months  hence.  The  disease  is  of 
exceedingly  rare  occurrence,  but  has  been  known  to  attack 
people  of  all  ages,  even  Httle  children.  Should  the  patient 
die,  the  autopsy  reveals  nothing  but  a  slight  reddening  of 
the  bronchial  mucous  membrane. 

The  chronic  variety  is  less  rare  than  the  acute,  and  is  most 
apt  to  occur  in  the  aged,  although  adults  are  not  free  from 
attack.  The  chief  symptom  is  the  expectoration  of  large 
quantities  of  characteristic  sputum,  amounting'  possibly  to 
four  or  six  pints  a  day.  The  general  health  of  the  individual 
may  not  suffer  for  years,  and  as  the  great  bulk  of  the  sputum 
is  sometimes  brought  up  in  a  morning  and  evening  attack, 
a  fairly  active  life  is  not  incompatible  with  the  disease.  In 
other  cases,  as  in  the  following,  recorded  in  his  Lumleian 
Lectures  by  the  late  Dr.  Gee,'^*  the  patient  is  completely 
incapacitated : 

"  A  Japanese,  twenty-five  years  old,  came  over  as  a  ship's  steward 
to  England,  and  immediately  upon  his  arrival  began  to  suffer  from 
shortness  of  breath  and  cough  :  a  new  thing  for  him.  After  these 
symptoms  had  lasted  for  fourteen  weeks,  he  was  admitted  to  the 
hospital.  There  was  much  dyspnoea  and  most  abundant  expectora- 
tion of  pituita.  Tubercle  bacilli  were  not  found.  The  physical 
signs  were  those  of  bronchitis.  For  days  together  he  seemed  about 
to  die  from  suffocation,  but  under  very  careful  treatment  he  improved 
until,  without  any  obvious  cause,  the  symptoms  recurred  in  full 
severity.  Another  improvement  was  followed  by  another  relapse,  and 
more  than  four  months  had  passed  away  since  his  admission  ere  he 
could  be  discharged  fairly  convalescent.  This  was  on  May  8,  but  on 
June  i6  he  was  readmitted,  with  all  his  former  symptoms ;  he  went 
out  on  July  i6.  On  December  5  he  was  readmitted  once  more,  and 
the  time  of  the  year  w^as  probably  the  reason  why  we  could  not  get 
rid  of  him  till  February  25.  He  had  now  been  a  patient  on  and  off 
for  more  than  a  year,  and,  as  there  seemed  no  end  to  this  sort  of  thing, 
the  Sister  of  the  ward  got  up  a  small  subscription  and  shipped  him 
off  to  the  Antipodes." 

2.  Bronchitis  Sicca  (Catarrhe  Sec). — Dry  catarrh,  or,  as  it 
is  better  termed,  "  bronchitis  sicca,"  was,  like  pituitous  catarrh, 
first  described  by  Laennec,  and,  according  to  him,  consists 


196  DISEASES   OF   THE   LUNGS   AND   PLEURA 

anatomically  in  a  swelling  of  the  mucous  mem.brane  of  the 
smaller  bronchi,  with  but  little  secretion.  The  swelling  is 
sometimes  so  intense  as  to  occlude  the  tubes,  whilst  in  other 
cases  the  remaining  lumen  is  obstructed  by  small  semitrans- 
parent  pearly-grey  masses  of  secretion  the  size  of  a  hemp  or 
millet  seed,  to  which  Laennec  gave  the  name  of  "crachats 
perles"  {"sputa  margaritacea,"  pearly  sputum).^"* 

Clinically,  the  disease  is  more  often  of  the  chronic  than 
of  the  acute  type,  and  produces  at  first  but  few  symptoms,  the 
patient  being  merely  somewhat  short  of  breath,  and  bringing 
up  in  the  morning,  with  an  occasional  cough,  a  few  pellets  of 
pearly  sputum.  As  the  disease  advances,  the  breath  becomes 
shorter,  the  cough  more  troublesome,  and  gradually  em- 
physema developes.  Every  now  and  then  acute  attacks  are 
experienced.  These  last,  perhaps,  three  or  four  days,  during 
which  the  cough  and  dyspnoea  are  accentuated,  and  then,  with 
the  expectoration  of  an  increased  amount  of  the  character- 
istic sputum,  the  symptoms  gradually  subside.  Sometimes 
an  acute  attack  occurs  quite  apart  from  any  pre-existing 
disease,  and  by  its  sudden  onset  and  marked  dyspnoea  gives 
rise  to  g'reat  anxiety.^' 

3.  Plastic  Bronchitis.— This  disease  is  characterised  by 
signs  of  bronchitis,  the  occurrence  of  a  plastic  exudation  into 
the  bronchial  tubes,  and  the  appearance  in  the  sputum  at 
recurring  intervals  of  the  casts  so  formed.  Cases  were 
observed  by  Galen  and  others  of  the  early  writers,  but  our 
actual  knowledge  of  the  malady  dates  from  the  appearance 
of  Lebert's  monograph  in  1869.^'^ 

The  disease  is  of  very  rare  occurrence,  and  twice  as  common 
in  the  male  as  in  the  female.  It  may  occur  at  any  age  from 
infancy  to  advanced  life,  but  most  of  the  recorded  cases  have 
commenced  between  the  ages  of  fifteen  and  fifty. 

Appearance  and  Nature  of  the  Casts. — The  branching  casts, 
which  we  associate  with  the  disease  (Plate  VIII.),  are  not  seen 
as  such  in  the  sputum.  When  expectorated,  they  are  gener- 
ally rolled  up,  and  appear  as  rounded  masses  covered  with 
mucus,  the  true  nature  of  which  is  apt  to  be  overlooked,  and 
it  is  not  until  they  are  floated  out  in  water  and  carefully 
unravelled  that  they  are  proved  to  be  moulds  of  the  bronchial 
tubes.  A  perfect  cast,  extending  sometimes  to  the  most 
minute  ramifications  of  the  bronchial  tree,  may  be  as  much 


PLATE  VIII 


iffUJi 


CASTS  EXPECTORATED  IN  PLASTIC  BRONCHITIS 

The  plate  shows  representations  in  actual  size  of  the  casts 
expectorated  in  this  disease.  That  on  the  right,  from  a  woman 
who  attended  the  Brompton  Hospital,  illustrates  the  extension 
of  the  plastic  inflammation  into  the  finest  bronchial  tubes ;  that 
on  the  left,  from  a  girl  aged  ten,  a  patient  at  St.  Bartholomew's 
Hospital,  shows  the  great  size,  to  which  such  casts  may  attain. 
The  history  of  this  second  case,  from  the  Museum  Catalogue,  is 
as  follows  : 

"  The  girl  had  suffered  from  intermittent  attacks  of  fibrinous 
bronchitis  since  her  seventh  year,  the  present  attack  being  the 
seventh.  The  illness  would  commence  suddenly  with  cough, 
headache,  and  malaise.  After  four  or  five  days  of  such  illness, 
which  was  attended  by  moderate  fever  and  dyspnoea,  she  would 
expectorate  casts  like  those  seen  in  the  specimen,  with  immediate 
relief  of  symptoms.  The  average  duration  of  an  attack  was 
about  four  weeks.  The  physical  signs  before  the  discharge  of  a 
cast  consisted  of  impaired  percussion  resonance  over  the  area 
concerned,  with  abolition  of  breath  and  voice  sounds,  and  dis- 
placement of  the  heart  towards  the  affected  side.  Discharge  of 
a  cast  temporarily  restored  the  physical  signs  in  the  chest  to  the 
normal.  The  child  left  the  hospital  well  some  seven  weeks  after 
the  onset  of  the  present  attack." 


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BRONCHITIS — BRONCHIAL   CATARRH  ig7 

as  seven  inches  long,  but  often  they  are  smaller  than  this, 
and  not  infrequently  are  expectorated  in  separate  little  pieces. 
In  appearance  they  are  white  or  yellowish  in  colour,  and  are 
sometimes  semi-transparent.  The  diameter  of  the  casts 
varies,  but  at  their  maximum  they  are  rarely  larger  than  a 
goose-quill.  On  section,  some  prove  to  be  soHd;  in  others 
a  lumen  is  found. 

When  examined  under  the  microscope,  the  cast  is  seen  to 
consist  of  an  outer  layer,  with  numerous  concentric  laminae, 
among"st  which  leucocytes  are  found  embedded.  In  some 
cases,  the  laminae  are  seen  to  be  formed  into  separate 
cylinders,  suggesting  "that  the  exudation  starts  in  the  fine 
bronchi,  and  is  then  gradually  pushed  up  into  the  larger 
tubes  "  (Bettmann).'""^ 

The  chemical  constitution  of  the  casts  has  given  rise  to 
much  discussion.  It  was  long  thought  that  they  were  com- 
posed chiefly  of  fibrin,  and  some  undoubtedly  are  of  this 
nature,  the  material  staining  by  Weigert's  method,  and  pre- 
senting the  chemical  characteristics  of  this  substance.  In 
other  cases,  though  a  few  threads  of  fibrin  may  be  present, 
the  great  mass  consists,  not  of  this  material,  but  of  mucin.'* 
Since,  therefore,  in  a  given  case  the  cast  may  prove  to  consist 
of  either  substance,  the  name  "  fibrinous  bronchitis,"  often 
used  to  indicate  the  disease,  is  hardly  applicable. 

With  regard  to  the  site  of  formation  of  the  casts  within 
the  bronchi,  Bierman  states  that  this  may  be  inferred  from 
the  length  of  the  intervals  between  successive  points  of  bifur- 
cation, and  Dr.  Ewart's  researches  into  the  structure  of  the 
bronchial  tree  would  corroborate  this.  It  is  important  to 
remember  that  the  bronchi  of  the  upper  lobe  are  peculiar  in 
presenting  short  and  rapidly  branching-  segments  as  com- 
pared with  the  elongated  tubes  of  the  lower  lobe.  The  calibre 
of  the  casts  would  also  be  of  assistance  in  deciding  the  ques- 
tion of  site. 

Altiology. — The  causation  of  the  malady  is  still  obscure. 
The  few  post-mortem  examinations  which  have  been  recorded 
have  revealed  nothing  beyond  slight  desquamation  of  the 
epithelium  of  the  affected  bronchi,  together  with  enlargement 
of  the  mucous  glands.  Bacteriology  has  given  but  little 
assistance.  In  the  casts  pneumococci,'  streptococci,  and 
Staphylococci  have  been  discovered,  but,  as  they  are  also  found 


198  DISEASES  OF  THE  LUNGS  AND  PLEURA 

in  simple  bronchitis,  their  presence  cannot  explain  the  peculiar 
features  of  this  variety.  The  Klebs-Loffler  bacillus  is  never 
found,  thus  proving-  that  the  complaint  has  no  connection 
with  diphtheria. 

In  certain  cases  plastic  bronchitis  has  occurred  during  the 
course  of  pulmonary  tuberculosis  or  of  morbus  cordis.  But 
neither  of  these  diseases  appears  to  possess  a  casual  relation- 
ship, and  at  present  the  true  pathology  of  the  malady  remains 
obscure.  In  some  cases,  as  in  one  that  has  come  under  our 
notice,  a  gouty  source  will  be  found  in  associated  arthritic 
phenomena.  The  malady  is  doubtless  analogous  in  some 
respects  with  the  mucous  colitis  with  which  we  are  more 
familiar. 

Symptoms. — In  the  majority  of  cases  the  disease  is  asso- 
ciated with  chronic  bronchitis,  which,  having  lasted  for  some 
months  or  years,  is  at  last  complicated  by  the  occurrence  of 
a  plastic  exudation.  The  cough  becomes  violent  and  as  a 
rule  paroxysmal;  the  dyspncea  may  be  extreme;  and,  finally, 
after  some  hours,  relief  is  obtained  by  the  expectoration  of 
masses,  which,  on  floating  out  in  water,  prove  to  be  bronchial 
casts.  After  the  attack  the  patient  generally  remains  better 
for  some  days,  though  still  coughing  up  fragments  of  casts, 
until  gradually  his  breathing  again  becomes  more  oppressed, 
the  cough  more  hard  and  paroxysmal,  and  a  second  attack  is 
experienced,  followed  perhaps  at  intervals  by  others.  With 
each  attack  a  mild  degree  of  pyrexia  may  be  associated,  and 
haemoptysis  sometimes  precedes  the  appearance  of  the  casts. 
After  a  time  the  patient  recovers,  though  still  remaining  the 
victim  of  chronic  bronchitis;  but  after  years  of  apparent 
immunity,  he  will,  perhaps,  suffer  a  recurrence  of  the  plastic 
attack.  Indeed,  the  tendency  of  the  disease  to  recur  forms 
one  of  its  most  noticeable  features. 

In  less  common  cases  plastic  symptoms  may  complicate  an 
attack  of  acute  bronchitis— the  first  from  which  the  patient  has 
suffered— but  in  other  respects  this  variety  of  the  disease, 
which  is  sometimes  spoken  of  as  acute,  does  not  differ  from' 
the  more  chronic  type  already  described. 

Physical  Signs.— The  signs  of  the  disease  are  very  indefinite, 
being  simply  those  of  general  bronchitis,  with  perhaps  a  cer- 
tain degree  of  dulness,  resulting  from  collapse,  with  very 
feeble  breath-sounds  over  the  area  of  bronchi  affected.  These 
signs  may  be  heard  over  any  part  of  the  lungs,  since  any  por- 


BRONCHITIS— BRONCHIAL   CATARRH  1 99 

tion  of  the  bronchial  tract  may  be  affected,  but  they  are  more 
common  at  the  base.  In  certain  cases,  when  the  cast  has 
become  loosened,  but  not  yet  expectorated,  a  coarse,  dry, 
clicking  sound — the  so-called  ventil-gerdusch  or  bruit  de 
drapeau — has  been  described  as  heard  on  auscultation,  due, 
it  is  believed,  to  the  flapping  backwards  and  forwards  of  the 
free  edge  of  the  cast  during  respiration."*  But  this  sign  is, 
in  our  experience,  exceptional,  and  the  recognition  of  the 
disease  must  rest  on  the  symptoms  rather  than  on  the  physical 
examination  of  the  patient. 

Diagnosis. — Diphtheria,  poisoning  with  ammonia  fumes, 
or  exposure  to  superheated  steam,  may  all  produce  a  mem- 
branous exudation  into  the  bronchial  tubes;  but  in  none  is 
the  disease  likely  to  be  confounded  with  the  malady  now 
under  consideration.  Again,  after  haemoptysis  semi-organ- 
ised blood-casts  are  sometimes  expectorated;  but  their  reddish 
colour  and  the  history  of  their  occurrence  explain  their 
pathology.  The  possibility  of  a  foreign  body  in  the  bronchus 
sometimes  arises,  and  then  requires  a  fresh  scrutiny  of  the  his- 
tory of  illness  and  special  examinations,  to  which  we  shall 
hereafter  refer  (Chapter  XIV).  Plastic  bronchitis,  in  fact,  is 
not  difficult  to  diagnose  when  its  presence  is  suspected.  When, 
therefore,  in  a  given  case  a  patient  suffers  from  attacks  of 
dyspnoea,  which  are  relieved  by  the  occurrence  of  expectora- 
tion, this  should  always  be  carefully  examined  for  casts,  any 
suspicious  rounded  mucoid  masses  being  teased  out  and 
unravelled  in  water.  If  this  were  done  more  frequently,  it 
is  probable  that  the  disease  would  be  recognised  as  less  rare 
than  at  present,  since,  in  a  certain  number  of  cases  in  which 
casts  have  been  discovered,  the  attacks  of  dyspnoea  have  been 
but  slight,  and  by  no  means  characteristic. 

Prognosis. — As  we  have  already  stated,  the  tendency  of 
plastic  bronchitis  is  to  recur,  and  by  thus  leading  to  em- 
physema, to  curtail  the  duration  of  life.  In  the  majority  of 
cases  the  attack  itself  does  not  prove  fatal;  nevertheless,  a 
study  of  the  literature  shows  that  the  danger  of  an  immediately 
fatal  issue  has  been  underestimated.  When  this  occurs,  it  is 
due  to  suffocation  from  the  dislodgment  of  an  extensive  cast, 
which  becomes  impacted  in  the  larynx — an  accident  most 
to  be  feared  in  the  very  old  or  very  young,  in  whom  cough 
is  least  effective." 


200  DISEASES   OF   THE   LUNGS   AND   PLEURA 

Treatment. — During  the  attack  our  endeavour  must  be  to 
assist  the  patient  in  expectorating-  the  casts.  To  this  end  the 
air  should  be  warmed  and  moistened  by  a  steam-kettle,  and, 
if  dyspnoea  be  urgent  and  suffocation  imminent,  an  emetic 
may  be  given.  Iodide  of  potassium  in  moderate  doses  is  of 
service  in  loosening  the  casts  and  in  preventing  their  fresh 
formation,  and  a  prolonged  course  is  indicated  in  cases  of  a 
markedly  recurrent  character.  It  is  possible  that  a  vaccine 
prepared  from  the  bronchial  secretion  might  prove  of  value. 


REFERENCES. 

'  "  English  Climatology,  1881-1900,"  by  Francis  Campbell  Bayard, 
LL.M.,  F.R.Met.Soc,  Qtiarterly  Journal  of  the  Royal  Meteorological 
Society,  January,  1903,  vol.  xxix..  No.  125,  p.  i. 

For  further  details  in  regard  to  climatology  for  periods  varying  from 
thirty  to  forty  years  ending  1910,  see  "  Monthly  Normals  of  Temperature, 
Rainfall,  and  Sunshine,"  the  Meteorological  Office,  London,  IQ15. 

^  Die  Krankheiten  der  Arbeiter,  Erster  Theil ;  Die  StaubinJialations- 
Krankheiten,  von  Dr.  Ludwig  Hirt.     Breslau,  1871. 

See  also  "  Industrial  Pneumonoconioses,  with  Special  Reference  to 
Dust-Phthisis,"  Milroy  Lectures.  1915,  by  Edgar  L.  Collis,  M.B.,  Public 
Health,  August  to  November,  1915. 

'  The  Annual  Oration  of  the  Medical  Society  of  London  on  "  Post- 
operative Lung  Complications,"  by  William  Pasteur,  M.D.,  F.R.C.P., 
Transactions  of  the  Medical  Society  of  London,  vol.  xxxiv.,  191 1,  p.  379. 

*  [a)  Manual  of  Tropical  Medicine,  by  Aldo  Castellani,  M.D.,  and  Albert  J. 
Chalmers,  M.D.,  F.R.C.S.,  D.P.H.,  2nd  edition,  London,  1913, 
p.  1283. 

[b]  "  Notes  on  '  Castellani's  Bronchospirochastosis,'  with  Report  of  a 
Case,"  by  G.  A.  Lurie,  M.D.,  Journal  of  Trofical  Medicine, 
December,  1915,  p.  269. 

[a)  "  Note  on  the   Importance  of  Hyphomycetes   and  other   Fungi   in 

Tropical    Pathology,"    by   Aldo    Castellani,    M.D.,    British   Medical 

Journal,  1912,  vol.  ii.,  p.   1208. 
{b)  Manual    of    Trofical   Medicine,    by    Aldo    Castellani,    M  D.,    and 

Albert  J.  Chalmers,  M.D.,  F.R.C.S.,  D.P.H.,  2nd  edition,  London, 

1913,  p.  1284. 

"  On  the  Pathology  of  Bronchitis,  Catarrhal  Pneumonia,  Tubercle,  and 
Allied  Lesions  of  the  Human  Lung,  by  Professor  D.  T.  Hamilton  dd  1^ 
et  seq.     London,  1S83.  '  ^^'  "^^ 

'  '=  Purulent    Bronchitis-a     Study    of    Cases    occurring    amongst    the 
British  Troops  at  a  Base  in  France,"  by  J.  A.  Hammond,  M.B.,  William' 
Rolland,  M.D.,  and  T.  H.  G.   Shore.  M.B.,  M.R.C.P.,  The  Lancet    1917 
vol.  11.,  p.  41.  ■    .' 


9 


BRONCHITIS — BRONCHIAL  CATARRH  201 

(a)  "  Purulent  Bronchitis  :  its  Influenzal  and  Pneumococcal  Bacteri- 
ology," by  Adolphe  Abrahams,  M.U.,  M.R.C.P.,  Norman  F. 
Hallows,  M.B.,  B.Ch.,  J.  W.  H.  Eyre,  M.D.,  M.S.,  D.P.H.,  and 
Herbert  French,  M.D.,  F.R.C.P.,  The  Lancet,  1917,  vol.  ii.,  p.  377. 

(b)  "A  Further  Investigation  into  Influenzo-Pneumococcal  and  Influ- 
enzo-Streptococcal  Septicaemia  :  Epidemic  Influenzal  '  Pneumonia  ' 
of  Highly  Fatal  Type  and  its  Relation  to  Purulent  Bronchitis,"  by 
Adolphe  Abrahams,  M.D.,  M.R.C.P.,  Norman  F.  Hallows,  M.D., 
D.P.H.,  and  Herbert  French,  M.D.,  F.R.C.P.,  The  Lancet,  1919, 
vol.  i.,  p.   I. 

"  Purulent  Bronchitis  complicating  Measles  and  Rubella,"  by  Lieut. - 
Colonel  W.  M.  Macdonald,  B.Sc,  M.D.,  M.R.C.P.,  Major  T.  R.  Ritchie, 
M.B.,  and  Lieut.  J.  C.  Fox,  M.R.C.S.,  and  P.  Bruce  White,  B.Sc, 
British  Medical  Journal,  1918,  vol.  ii.,  p.  481. 

"  "  The  Filter-Passing  Virus  of  Influenza,"  by  John  Rose  Bradford, 
E.  F.  Bashford,  and  J.  A.  Wilson,  with  an  Appendix  by  F.  Clayton,  the 
Quarterly  Journal  of  Medicine,  vol.  xii..  No.  47,  April,  1919,  p.  259. 

"  The  Pharmacopoeias  of  Thirty  of  the  London  Hospitals,  by  Peter  Squire. 
London,  1910. 

'"  [a)  Medical  Lectures  and  Aphorisms,  by   Samuel   Gee,   M.D.,   p.    70. 
London,  1902. 
[b]  Loc.  cit.,  p.  74. 

"  For  a  careful  study  of  the  suitability  of  the  various  health  resorts, 
reference  may  be  made  to  The  Climates  and  Baths  of  Great  Britain  and  Ire- 
land, being  the  Report  of  a  Committee  of  the  Royal  Medical  and  Chirur- 
gical  Society  of  London,  vols.  i.  and  ii.     London,  1895  and  1902. 

"  (a)  Traite  de  V Auscultation  Mediate  et  des  Maladies  des  Poumons  et  du 
Cceur,  par  R.   T.   H.   Laennec,   troisieme  edition,   tome  i.,  p.    151. 
Paris,  1831. 
{b)  Loc.  cit.,  p.  161. 

"  For  an  interesting  example  of  this  condition,  see  The  Collected  Works 
of  Dr.  P.  M.  Latham,  New  Sydenham  Society  edition,  vol.  ii.,  p.  118. 
London,  1878. 

"  "  Ueber  das  Vorkommen  fibrinoser  Entziindungs-Producte  in  den 
Bronchien  und  Lungen-Alveolen — Ueber  fibrinose  oder  pseudo-membranose 
Bronchitis  und  Pneumonie — Bronchitis  fibrinosa.  Bronchitis  pseudo- 
membranacea — Pneumonia  fibrinosa,"  von  Dr.  Lebert,  Deutsches  Archiv 
fiir  Klinische  Medicin.     Leipzig,   1869,  vol.  vi.,  p.   126. 

^"  [a]  "  Report  of  a  Case  of  Fibrinous  Bronchitis,  with  a  Review  of  all 
Cases  in  the  Literature,"  by  Milton  Bettmann,  M.D.,  The  American 
Journal  of  the  Medical  Sciences,   1902,  vol.  cxxiii.,  p.    304. 
{b)  Loc.  cit.,  p.  313. 

For  a  review  of  the  evidence  on  this  subject,  and  a  bibliography 
thereon,  see  Dr.  Musser's  report  in  Diseases  of  the  Bronchi,  Lungs,  and 
Pleura;  NothnagePs  Encyclopedia  of  Practical  Medicine,  p.  158,  Englisl^ 
edition,  Philadelphia  and  London,  1903. 

For  report  of  a  fatal  case  in  a  boy,  aged  six,  see  British  Medical 
Journal,  1915,  vol.  ii.,  epit.  No.  :^i2. 


CHAPTER  XIII 

NARROWING  AND  DILATATION  OF  THE  BRONCHI 

Narrowing  of  the  Bronchi.— G^wera/  narroimng  of  the  bronchi 
is  practically  only  met  with  as  a  consequence  of  swelling  of 
the  mucous  membrane  in  catarrhal  affections  or  exudative 
maladies  such  as  plastic  bronchitis  and  diphtheria.  Doubt- 
less cases  may  occur  in  which  there  is  some  general  diminu- 
tion in  the  calibre  of  the  bronchial  system,  but  they  are  not 
recognisable  during  life. 

Localised  narrowwg  of  a  bronchus  may  arise  from: 
(i)  Cicatricial  contraction  of  an  ulcerated  surface  within  the 
bronchus;  (2)  contractile  sclerosis  of  the  bronchial  sheath  at 
one  or  more  points;  (3)  invasion  of  the  calibre  of  the  bronchus 
by  malignant  growths;  (4)  pressure  upon  the  bronchus  by 
enlarged  glands,  growths,  hydatid  or  aneurismal  tumour. 
Let  us  now  consider  these  causes  in  further  detail. 

(i)  The  cicatricial  changes  ensuing  upon  ulceration  are 
amongst  the  very  rare  causes  of  bronchial  narrowing,  and 
are  almost  always  of  syphilitic  origin. 

(2)  In  association  with  the  more  chronic  indurative  form 
of  phthisis,  it  is  not  uncommon  to  find  at  certain  points 
bronchial  tubes  narrowed  or  even  obliterated  by  what  may 
be  regarded  as  cicatricial  growths  involving  the  sheath  of 
the  bronchus.  This  change  may  occur  at  points  adjacent  to 
tuberculo-fibroid  nodules,  or  at  the  entrance  to  cavities  which 
have  undergone  considerable  or  complete  contraction  and 
are  surrounded  by  a  zone  of  cicatricial  induration  in  which 
the  entering  bronchus  is  involved.  In  this  way  partially  con- 
tracted cavities  are  not  infrequently  closed.  Sometimes 
when  a  cavity  becomes  thus  shut  off  by*  occlusion  of  its 
communicating  bronchus,  the  purulent  contents  subse- 
quently inspissate  into  a  creamy  debris,  which  at  a  later  period 
becomes  cretaceous.     In  other  cases  the  purulent  secretions 


202 


NARROWING   AND    DILATATION    OF   THE    BRONCHI        203 

increase,  and,  becoming  pent  up,  cause  elevation  of  tempera- 
ture and  other  signs  of  abscess;  finally,  when  they  attain  to 
a  certain  degree  of  pressure,  the  narrowed  bronchus  yields, 
and  a  discharge  takes  place,  after  which  accumulation  again 
commences. 

(3)  and  (4)  The  invasion  of  malignant  growths  and  the 
pressure  of  tumours  are  amongst  the  most  common  causes 
of  obstruction  to  the  main  bronchi;  and  are  of  too  obvious  a 
mechanism  to  require  further  exposition. 

The  necessary  consequences  of  narrowing  of  a  bronchus 
at  any  point  are  (a)  more  or  less  complete  retention  of  secre- 
tion behind  the  obstruction;  (b)  variable  changes  of  a 
destructive  kind  in  the  lung  itself. 

In  cases  in  which  the  secretion  is  derived  from  the  bron- 
chial mucous  membrane,  the  lung,  not  being-  as  yet  involved, 
it  is  thick,  viscid,  and  muco-purulent,  and  collects  in  such 
quantities  as  to  distend  the  bronchi  behind  the  obstruction. 
When  sufficient  distension  has  taken  place,  a  paroxysmal 
cough  will  expel  through  the  narrowed  orifice  a  certain  por- 
tion, the  overflow,  so  to  speak,  of  the  collection,  in  the  form 
of  thick,  viscid,  and  more  or  less  nummulated  sputa,  gener- 
ally not  offensive. 

The  condition  of  lung  that  attends  narrowing  of  a  bronchus 
is  in  the  later  stages  one  of  airless  collapse,  to  be  followed 
shortly  by  more  or  less  thickening  and  fibrosis  of  the  pul- 
monary structure,  with  dilatation  of  the  tubes  behind  the 
stricture.  As  contended  by  the  late  Dr.  Pearson  Irvine,'  and 
more  recently,  in  his  Bradshaw  lecture  by  Dr.  Newton  Pitt,^ 
dilatation  of  the  affected  lung,  sometimes  even  suflficient  to 
suggest  pneumothorax,  may  be  the  primary  consequence  of 
pressure  upon  the  bronchus,  the  effect  of  the  narrowing  being 
to  impede  expiration,  whilst  inspiratory  effort  is  successful. 
Such  primary  dilatation  is,  however,  but  rarely  seen,  and  it  is 
probable  that  so  soon  as  secretion  begins  to  collect  behind 
the  obstruction,  the  air-cells  can  no  longer  be  penetrated  by 
air,  whilst  that  which  remains  in  them  must  slowly  be  expelled 
or  absorbed.  Secondary  changes  of  a  destructive  character 
not  infrequently  ensue  in  a  lung,  the  main  bronchus  of  which 
is  thus  occluded  by  pressure,  changes  which  were  thought 
by  the  late  Sir  William  GulP  to  arise  from  disturbed  innerva- 
tion through  pressure  upon  the  pulmonary  plexuses.     But 


204  DISEASES   OF   THE   LUNGS   AND   PLEURA 

there  can  be  little  doubt  that  in  the  great  majority  of  cases 
we  must  trace  these  changes,  not  to  any  nervous  influence, 
but  to  the  retention  of  secretions  which  necessarily  become 
more  or  less  septic— a  condition  analogous  to  that  met  with 
in  the  kidney  in  old-standing  hydro-  or  pyonephrosis,  and  also 
in  other  obstructive  urinary  diseases. 

The  Symptoms  and  Signs  of  bronchial  narrowing  need 
only  be  considered  with  regard  to  those  cases  in  which  the 
constriction  is  situated  at  one  or  other  main  bronchus.  In 
these  cases  the  signs  of  narrowing  of  the  bronchus  some- 
times present  themselves  before  the  cause  of  the  narrowing 
can  be  precisely  made  out. 

Relatively  feeble  breath-sounds  of  harsh  or  blowing  quahty 
over  one  lung,  most  frequently  in  the  upper  interscapular 
region  of  the  affected  side,  are  the  first  signs  to  be  observed. 
The  percussion  note,  at  first  unaltered,  becomes  of  higher 
tone  over  the  affected  area,  the  vocal  fremitus  and  resonance 
being  at  the  same  time  lessened.  The  exaggeration  of  the 
vesicular  breathing  on  the  healthy  side  is  in  marked  contrast 
with  its  feebleness  and  Avant  of  vesicularity  on  the  opposite 
side. 

Soon  a  further  sign,  stridor,  makes  its  appearance.  At 
first  slight,  and  only  heard  occasionally,  it  gradually  becomes 
more  marked,  until  even  when  at  rest  each  inspiration,  and 
to  a  less  degree  each  expiration,  is  attended  with  a  coarse, 
stridorous  noise.  Sometimes,  too,  we  may  notice  recession 
over  the  affected  side,  a  sign  which,  in  conjunction  with  the 
preceding,  is  most  suggestive.  As  the  case  proceeds,  the 
feebleness  of  the  breath-sound  becomes  increased  to  final 
extinction,  while  the  diminished  mobility  and  shrinking  of 
the  side,  with  impaired  percussion  note,  becomes  more  definite. 

From  the  first  there  is  cough,  which  may  be  of  laryngeal 
type,  from  involvement  of  the  nerves  of  the  larynx  concur- 
rently with  the  bronchial  compression.  The  cough  is,  more- 
over, generally  spasmodic  in  character,  the  passage  of  the 
thick  sputa  through  the  stricture  giving  rise  always  to  more  or 
less,  sometimes  to  very  severe,  paroxysms  of  dyspnoea.  As 
pulmonary  collapse  proceeds,  pleuritic  pains  and  the  signs  of 
dry  pleurisy  present  themselves,  and,  with  advancing  dulness, 
may  lead  the  observer  away  from  the  right  diagnosis.  The 
heart   is,  uncovered   and    shifted   towards    the    affected    side, 


NARROWING   AND    DILATATION    OF   THE   BRONCHI        205 

unless  its  position  be  otherwise  determined  by  the  pressure 
of  a  tumour. 

In  the  most  common  class  of  cases,  those  in  which  the 
narrowing-  is  due  to  the  compression  of  an  aneurism  or 
malignant  growth,  other  signs  of  pressure,  ocular,  laryngeal, 
and  so  forth,  will  as  a  rule  be  present,  thus  throwing  helpful 
light  upon  the  nature  of  the  affection.  It  is  in  cases  of  this 
kind  also  that  assistance  may  be  looked  for  from  an  X-ray 
examination,  a  definite  pulsating  aneurismal  tumour,  for 
instance,  being  sometimes  revealed,  when  from  the  physical 
signs  alone  it  would  have  been  impossible  to  arrive  at  a  cer- 
tain diagnosis. 

In  cases  of  syphilitic  narrowing  there  will  be  the  history  of 
syphilis,  the  signs  of  narrowing,  and  the  absence  of  those  of 
tumour.  In  an  interesting  case  that  has  come  under  our 
notice,  in  which  the  left  bronchus  was  almost  obliterated,  and 
the  lower  portion  of  the  trachea  narrowed  by  syphilitic 
cicatrices,  in  addition  to  an  absence  of  the  signs  of  aneurism, 
it  was  observed  that  the  patient's  distress  was  greatly 
increased  by  an  attempt  to  lie  in  the  prone  position,  and  that 
he  felt  most  easy  when  erect  and  walking  about  the  room.. 
In  aneurism  the  patient's  troubles  are  much  increased  by 
movement,  whilst  the  prone  position  sometimes  gives  ease 
from  the  falling  forward  of  the  aneurism  and  the  consequent 
relief  of  pressure. 

Treatment. — The  cause  of  the  constriction,  be  it  aneurism 
or  syphilis,  must  be  appropriately  treated;  and  in  most  cases 
much  may  be  done  in  the  way  of  giving  ease. 

Reg'ulated  doses  of  chloroform  for  inhalation  are  valuable 
in  relieving  spasmodic  cough  and  in  aiding  expectoration. 
For  this  purpose  a  few  drops  of  chloroform  at  a  time  may 
be  placed  upon  absorbent  cotton-wool  in  a  small  bottle  to 
be  sniffed.  We  have  also  known  a  pungent  vapour,  such  as 
strong  peppermint  essence  in  hot  water  inhaled  through  the 
nostrils,  to  give  relief.  In  cases  in  which  the  paroxysmal 
dyspnoea  arises  from  compression  of  the  bronchus  by 
aneurism,  nitro-glycerine  (i  minim  of  the  liquor  trinitrini) 
will  assist  by  lessening  tension  within  the  sac.  Expectorant 
remedies  are  worse  than  useless.  Chloral  and  paraldehyde 
give  more  promise  of  usefulness  than  opiates.  Indeed,  chloral 
in  small  repeated  doses  is  a  most  valuable  drug  in  lessening 


266 


DISEASES   OF   THE  LUNGS   AND   PLEURAE 


the  spasm  which  always  intensifies  the  symptoms  in  cases  of 
narrowing-  of  the  main  bronchus,  thus  giving'  time  for  other 
remedies,  such  as  iodide  of  potassium  and  mercury,  to  take 
effect. 

When  the  main  bronchus  is  involved  the  prognosis  is  of  the 
gravest  character. 

Dilatation  of  the  Bronchi — Bronchiectasis. — This  affection 
consists  in  a  manifest  widening  of  the  bronchial  tubes  over  a 
more  or  less  limited  area.  It  is  by  no  means  a  common 
disease,  and  occurs  much  more  frequently  in  males  than  in 
females.  It  is  more  rare  among  the  well-to-do  than  among 
the  poor. 

No  age  is  exempt  from  it,  but,  as  indicated  by  the  following 
statistics,  compiled  from  the  records  of  the  Brompton  Hos- 
pital by  Dr.  D.  Barty  King,  it  is  most  common  between  the 
ages  of  ten  and  forty.  We  must  note,  however,  that  in  this 
table  the  incidence  of  the  disease  in  the  first  decade  of  life 
is  probably  underestimated,  owing  to  the  fact  that  the 
number  of  children  admitted  into  the  Brompton  Hospital  is 
limited. 

Table  showing  the  Age-Incidence  in  Sixty  Cases  of  Bronchiectasis 

FROM  All  Causes." 


Age. 

Number  of  Cases. 

Per  Cent. 

o-io     ... 

I 

1-6 

I0-20      ... 

14 

233 

20-30      

15 

25"0 

30-40      

16 

26-6 

40-50      

8 

13-4 

50-60      

4 

67 

60-70      ... 

2 

3 '4 

Total      ... 

60 

lOO'O 

Morbid  Anatomy.— Anatomically,  the  disease  appears  in 
two  chief  forms :  the  cylindrical  and  the  sacculated.  In 
cylindrical  or  fusiform  bronchiectasis  the  dilatation  involves 
some  length  of  the  tubes,  varying  from  a  few  inches  to  a 
system  of  tubes  ramifying  through  an  entire  lung.  The 
enlargement  is  uniform  throughout  the  length  of  tubes 
affected,  though  sometimes  at  the  distal  end  of  the  tube 
there  may  be  a  further  ampullary  dilatation.     In  sacculated 


PLATE    IX 


CYLINDRICAL  BRONCHIECTASIS 

The  specimen  shows  the  left  lung  cut  open  and  the  sides 
turned  back.  On  the  left  hand  the  specimen  has  been  untouched ; 
on  the  right  the  bronchi  have  been  opened  up  to  show  the  general 
cylindrical  dilatation.  On  examining  the  left-hand  portion,  the 
lung  is  seen  to  present  the  appearance  of  being  filled  with  ovoid 
cavities,  which  varied  in  size  from  a  bean  to  a  bantam's  egg. 
An  examination  of  the  right-hand  portion,  however,  shows  that 
these  apparently  separate  cavities  are  in  reality  sections  cut  at 
varying  angles  of  the  bronchi,  which  throughout  their  course 
are  dilated  in  a  cyhndrical  manner,  with  in  some  cases  a  further 
terminal  expansion.  Between  the  dilated  bronchi  the  lung 
tissue  has  undergone  fibrosis.  The  pleura  is  everywhere  ad- 
herent, but  not  much  chickened. 

From  a  man  aged  twenty-one,  who  suffered 'from  bronchi- 
ectasis with  much  cough  and  foetid  expectoration,  and  who  died 
from  an  abscess  in  the  right  frontal  lobe.  The  right  lung  con- 
tained some  patches  of  recent  broncho-pneumonia,  but  the  bronchi 
were  not  dilated.     The  spleen  showed  lardaceous  degeneration. 

(From  the  Brompton  Hospital  Museum.     {%  natural  size.) 


PLATE  X 


r.  I A 


Saccular  Bronchiectasis. 


To  face  p.  207. 


SACCULAR  BRONCHIECTASIS 

The  drawing  shows  a  portion  of  the  left  lung  in  a  condition 
of  advanced  saccular  bronchiectasis.  The  lung  is  shrunken,  and 
its  substance  has  given  place  to  smooth-walled  cavities  of  various 
size,  separated  from  each  other  by  trabeculae  of  fibrous  tissue,  in 
which,  under  the  microscope,  a  few  pulmonary  alveoli  may  still 
here  and  there  be  detected.  The  pleural  layers  are  adherent. 
Microscopical  examination  showed  the  cavities  to  be  formed  by 
dilatation  of  the  bronchi  and  bronchioles ;  their  walls  were  lined 
by  granulation  tissue,  with  no  trace  of  epithelium  remaining. 
The-  right  lung  was  emphysematous,  and  contained  in  its  lower 
lobe  a  few  cavities  similar  to  those  on  the  opposite  side.  The 
heart  was  dilated  and  drawn  over  to  the  left. 

From  a  man  aged  twenty-eight,  who  died  of  heart  •  failure, 
after  suffering  for  twelve  months  from  shortness  of  breath,  and 
for  three  weeks  from  dropsy. 


(From  the   Museum   of   St.    Bartholomev/'s   Hospital,     -l   natural 

size.) 


PLATE   X 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        20; 

bronchiectasis  a  restricted  portion  of  a  tube  is  enlarged  to  a 
globular  form,  from  a  quarter  of  an  inch  to  an  inch  in 
diameter.  The  whole  caHbre  of  the  tube  is  generally  involved, 
and  the  dilatation  may  be  solitary  or  there  may  be  many 
scattered  through  the  lung.  Small  openings  lead  from  the 
rounded  and  apparently  closed  distal  side  of  the  sacs  to  fine 
tubes,  the  branchlets  of  the  widened  bronchus.  The  illus- 
trations (Plates  IX.  and  X.)  show  the  naked-eye  appearances 
presented  by  these  two  varieties  of  the  disease. 

Of  the  two  forms,  the  cyHndrical  is  by  far  the  more 
common,  though  it  may  be  combined  with  a  certain  degree 
of  saccular  dilatation.  It  is  probable,  indeed,  that  not  a  few 
of  the  cases  which  have  been  described  as  saccular  have  been 
in  reality  examples  of  the  cylindrical  form  in  which  the  tubes 
have  been  cut  at  varying  angles,  thus  giving  in  a  section 
of  the  lung  the  appearance  of  more  or  less  rounded  cavities 
of  different  size.  In  such  cases  it  is  only  by  slitting  up  the 
bronchi  throughout  their  length  that  the  true  nature  of  the 
case  becomes  apparent  (see  Plate  IX).  In  other  instances, 
again,  in  which  a  bronchus  does  open  directly  into  a  large 
sacculated  cavity,  we  must  hesitate  before  assuming  that  the 
cavity  in  question  is  necessarily  of  simple  bronchial  origin, 
even  thoug'h  there  may  be  definite  evidence  elsewhere  of 
dilatation  of  the  tubes.  Not  uncommonly  it  is  due,  in  part  at 
least,  to  gangrene,  whereby  the  walls  of  adjacent  bron- 
chiectatic  cavities  are  destroyed,  thus  producing  extensive 
and  irregular  excavations.  These  sometimes  closely  resemble 
true  pulmonary  vomicae.  The  distinction  is  made  post- 
mortem by  finding  in  the  cavity  walls  remnants  of  cartilage, 
which  reveal  the  original  nature  of  the  dilatation. 

Bronchiectasis,  whether  cylindrical  or  saccular  in  nature, 
may  be  met  with  in  any  area  of  the  lung,  and  in  any  lobe; 
but  it  is  most  common  in  the  lower  lobe,  since  here  retention 
of  secretion,  a  potent  factor  in  the  aetiology  of  the  disease, 
is  more  liable  to  occur  than  in  the  upper  lobes,  where  gravita- 
tion assists  in  emptying  the  tubes.  Out  of  fourteen  cases  of 
simple  bronchiectasis  (unassociated  with  tubercle)  in  which 
the  autopsy  was  made  by  one  of  us,^  in  two  only  was  the 
disease  limited  to  the  upper  lobe;  in  a  third  it  was  most 
marked  in  this  situation,  though  affecting-  other  lobes  as  well. 
In  the  remainder  the  disease  had  apparently  commenced,  as 


208  DISEASES    OF  THE  LUNGS   AND   PLEURA 

usual,  at  the  base  of  tlie  lung.  But  at  the  time  of  death,  the 
condition  is  not  commonly  Hmited  to  the  lobe  first  affected. 
Thus,  if  we  add  to  the  35  cases  from  the  Brompton  records 
quoted  by  Sir  J.  Kingston  Fowler,^"  the  14  more  recent  ones 
referred  to  above,  we  obtain  a  total  of  49  autopsies.  Analysing 
these,  we  find  that  in  31  cases  (63  per  cent.)  both  lungs  were 
affected  at  the  time  of  death,  in  18  {-^y  per  cent.)  one  lung  only; 
in  only  12  cases  (24' 5  per  cent.)  was  the  lesion  limited  to  one 
lobe.  We  may  add  that  when  the  disease  passes  from  one 
lung  to  affect  the  other,  it  is  again  the  lower  lobe  which  is 
usually  first  affected,  the  tendency  of  the  disease  being  to 
extend  from  below  upwards. 

Etiology. — If  we  exclude  certain  rare  cases  of  congenital 
origin,  which  are  probably  to  be  regarded  as  malformations 
or  errors  of  development,  it  may  be  said  that  bronchiectasis 
is  never  a  primary  disease.  It  is  dependent  upon  either 
increased  pressure  within  the  tubes  or  traction  upon  their 
walls,  a  necessary  phase  in  all  cases  being  some  structural 
change  in  the  bronchial  tissues. 

The  causes  may  be  classified  under  three  headings :  (i) 
bronchial;  (2)  pulmonary;  and  (3)  pleural;  the  relative  impor- 
tance of  which  may  be  gauged  from  the  following  table  based 
upon  the  records  of  the  Brompton  Hospital,  which  we  have 
taken  from  Dr.  Acland's  paper.* 

Table  showing  the  Causes  or  Antecedent  Conditions,  as  far  as  could 
BE  ascertained,  IN  Forty  Cases  of  Bronchiectasis,  verified  by  Post- 
mortem Examination. 


Disease. 

1 

i  Number  of  Cases. 

1 

Percentage. 

1.  Chronic  bronchitis             

Chronic  cough  since  childhood  ... 
Bronchial  stenosis- 
Tumour     ... 

Aneurism  ... 

Foreign  body      

2.  Pneumonia 

3.  Pleurisy        

11 

1 

4 

5 

600 

-77-5 

17-5; 

lo-o 

12-5 

Let  us  now  consider  the  various  causes  in  more  detail. 
I.  Bronchial. — From  the  table  which  we  have  just  given, 
it  will  be  evident  that  affections  of  the  bronchi  play  by  far 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        209 

the  most  important  role  in  the  aetiology  of  bronchiectasis. 
"  Chronic  bronchitis  "  and  "  chronic  cough  "  account  for  more 
than  half  (60  per  cent.)  of  the  cases  quoted,  and  bronchial 
stenosis  is  responsible  for  another  I7'5  per  cent.,  making  a 
total  of  77' 5  per  cent.,  thus  leaving  only  22  per  cent,  to  be 
accounted  for  by  pneumonia  and  pleurisy. 

In  regard  to  the  relation  of  chronic  bronchitis  to  bron- 
chiectasis, there  can  be  little  doubt  that  the  disease  is  deter- 
mined by  two  factors :  (a)  changes  of  an  inflammatory  kind 
occurring  in  the  deeper  layers  of  the  bronchial  mucous  mem- 
brane, to  which  we  have  referred  in  the  chapter  on  bronchitis  ; 
(b)  the  rending  force  of  the  cough  distending  the  tubes,  the 
elasticity  of  which  has  already  become  permanently  impaired. 
It  is  the  state  of  nutrition  of  the  walls  of  the  bronchial  tubes 
which  is  the  determining  factor  as  to  whether  they  will  yield 
or  not  under  the  stressful  conditions  of  chronic  cough.  In 
cases  in  which  the  texture  of  the  walls  has  been  damaged  by 
inflammatory  change  bronchiectasis  is  apt  to  occur,  and  it  is 
in  this  regard  that  any  condition  involving  retention  of  secre 
tion  has  so  damaging  an  influence.  Thickening  of  the  sur- 
rounding lung  tissue  which  to  some  extent  accompanies  the 
dilatation  proceeds  further  after  the  bronchiectasis  is  estab- 
lished. 

The  inhalation  of  a  foreign  body  into  a  bronchus  is  not  of 
common  occurrence,  hence  bronchiectasis  is  not  often  pro- 
duced in  this  way.  But  the  possibility  that  a  foreign  body 
may  be  at  the  root  of  the  malady  must  be  borne  in  mind 
in  every  case,  since  its  early  detection  and  removal  by 
bronchoscopy  may  be  the  means  of  curing  the  patient,  or  at 
least  preventing  the  occurrence  of  more  than  a  mild  degree  of 
bronchial  dilatation.  As  we  shall  point  out  in  the  succeeding 
chapter  (see  p.  232),  the  symptoms  due  to  the  inhalation  of 
the  foreign  body  may  be  slight,  and  therefore  in  every  case 
of  bronchiectasis  careful  inquiry  must  be  made  as  to  any 
history  suggestive  of  such  an  occurrence.  In  the  museum 
of  the  Brompton  Hospital  may  be  seen  specimens  of  bron- 
chiectasis due  to  such  different  matters  as  a  molar  tooth,  an 
ear  of  corn,  and  in  two  cases  a  piece  of  bone,  in  one  of  which 
'there  was  no  history  of  the  inhalation. 

It  is  interesting  to  note  that  a  tumour  growing  from  the 
interior  of  the  bronchus  and  partially  occluding  it  may  act 

14 


210  DISEASES    OF   THE  LUNGS   AND   PLEURA. 

like  a  foreign  body  and  lead  to  bronchiectasis,  though  such 
primary  growths  are  of  great  rarity/ 

2  and  3.  Pulmonary  and  Pleural. — When  the  vesicular  tex- 
ture of  a  lung  is  obliterated  by  permanent  collapse  or  fibrous 
growth,  the  tendency  of  the  inspiratory  force  is  to  widen  the 
bronchial  tubes  which  traverse  that  lung;  and  as  the  con- 
densed tissues  in  which  the  tubes  are  embedded  further  con- 
tract, the  widening  becomes  more  marked.     Secondaiy  to  a 
pneumonia  more  often  broncho-pneumonic  in  character,  or 
a  dry  pleurisy,  a  portion  of  a  lung,  perhaps  a  whole  lobe,  will 
thus  in  certain  cases  become  condensed  by  connective-tissue 
growth,  which  extends  from  the  pleura  along  the  interlobular 
septa  and  from  the  sheaths  of  the  bronchi  and  vessels.     The 
fibrous  overgrowth  thus  produced  has  been  termed  chronic 
interstitial    pneumonia    (see    Chapter    XIX.).     The    pleura] 
surfaces     under     these     conditions     are     almost     invariably 
adherent,    and    the    lung    being     held    attached   at    its    cir- 
cumference by  the  adhesions,  and  its  bronchial  tubes  fixed 
at   the   root,   it   is   clear   that    when   the    thoracic    wall   has 
receded,  and  the  surrounding  organs,  thoracic  and  abdominal, 
have    approximated   as    far    as    possible,    any    further    con- 
traction  of  the  lung  must  drag  upon   the  bronchial  tubes 
and  extend  their  calibre  in  all  directions.     As  the  result,  the 
medium  and  subcapillary  tubes  embedded  in  the  depth  of  the 
lung  become  widened  out  into  fusiform  and  globular  cavities, 
the  finest  tubes  becoming  extensively  obliterated  in  the  course 
of  the  contractile  disease. 

In  cases  of  thoracentesis  for  old-standing  empyemata,  bron- 
chiectasis amounting  to  complete  loculation  of  lung  may 
arise  in  a  manner  not  essentially  different  from  that  just 
described.  In  such  cases  obliteration  of  the  pleural  cavity  is 
finally  effected  from  above  downwards  by  the  gradual  growth 
of  adhesions  agglutinating  the  pleural  surfaces.  The^'paren- 
chyma  of  the  lung  is,  however,  in  these  cases  irretrievably 
condensed,  so  that  the  degree  of  enlargement  of  the  organ 
necessary  to  fill  the  remaining  thoracic  space  is  only  to  be 
obtained  by  widening  out  the  bronchial  tubes,  and  further 
contraction  of  the  fibrous  lung  must  continue  to  have  the 
same  effect.  Thus  the  lung  in  some  cases  comes  to  be  a ' 
mere  shell,  enfolding  bulbous  bronchial  cavities. 

In  congenital  collapse  of  any  portion  of  the  lungs— a^d^c- 


o 

td 
H 

O 
W 

u 

<: 
« 
<: 
w 

<1 
Q 


w 

< 


ACUTE  BRONCHIOLECTASIS 

{The  "  Honeycomb  Lung  ") 

The  drawings  show  the  appearance  of  the  lung.  On  the  outer 
surface  numerous  bullae  are  seen,  while  the  cut  section  presents 
a  general  honeycombed  appearance,  due  to  the  presence  of 
innumerable  small  cavities.  Microscopical  examination  proved 
that  these  v/ere  dilated  bronchioles,  with  inflamed  and  infiltrated 
walls.  There  was  a  marked  degree  of  acute  emphysema,  but  no 
evidence  of  tubercle. 

From  a  child  aged  three  and  a  half  years,  who  died  of  acute 
bronchitis  after  an  illness  of  only  twelve  days. 

(From  the  Museum  of  St.   Bartholomew's  Hospital. 
Natural  size.) 


PLATE  XI 


NARROWING   AND    DILATATION   OF   THE   BRONCHI       211 

tasis  pulmonum — the  bronchial  tubes  ramifying  through  that 
portion  are  widened. 

Bronchiectasis  having  been  induced  as  a  result  of  one  of 
the  causes  described  above,  certain  further  changes  now 
occur  in  the  dilated  tubes.  The  secretions  in  them  tend  to 
accumulate,  partly  from  the  altered  shape  of  the  tubes  and 
the  destruction  of  their  ciliated  epithelium,  and  partly  owing 
to  the  hardened  tissue,  by  which  they  are  surrounded,  render- 
ing effectual  expulsion  with  cough  impossible.  Decomposi- 
tion of  the  stagnant  secretion  generally  follows,  resulting  in 
septic  inflammation  of  the  cavity  walls  and  of  the  adjacent 
parts.  It  is  in  this  stage  that  neighbouring  bronchiectatic 
cavities  may  coalesce  from  softening  or  gangrene  of  their 
walls,  and  thus  give  rise  to  the  irregular  excavations  of  the 
lung  to  which  we  have  referred. 

We  have  spoken  hitherto  of  chronic  bronchitis  as  a  cause 
of  bronchiectasis,  but  we  must  add  that  in  young  children 
acute  bronchitis  may  also  lead  to  dilatation  of  the  tubes.  In 
this  case,  however,  as  shown  by  Dr.  Sharkey^  and  others,  the 
dilatation  commonly  affects  not  the  larger  bronchi,  but  the 
bronchioles,  giving  to  the  lung  a  curious  worm-eaten 
appearance — the  so-called  "honeycomb  lung" — owing  to  the 
innumerable  small  saccular  cavities  distributed  throughout 
(Plate  XL).  These  also  appear  on  the  surface  of  the  organ 
as  small  round  transparent-looking  vesicles.  This  variety  of 
the  disease,  in  its  marked  stages  at  least,  is  not  common,  and 
is  of  little  importance  clinically,  since  it  cannot  be  dis- 
tinguished from  the  antecedent  bronchitis.  From  its  some- 
what special  features  it  has  been  named  "  acute  bron- 
chiectasis" or  "  bronchiole ctasis."  It  is  possible  that  there 
may  be  a  recovery,  partial  at  least,  from  this  acute  dilatation 
of  the  tubes. 

Symptomatology.— The  symptoms  of  bronchiectasis  differ 
much  in  different  cases,  and  may,  indeed,  be  entirely  absent. 
Thus  at  the  autopsy  of  a  patient  who  died  of  acute  bronchitis 
we  have  found  marked  cyHndrical  dilatation  of  the  bronchi 
in  the  right  upper  lobe,  though  there  had  been  no  symptoms 
referable  to  this  during  life,  and  though  the  disease  had 
evidently  been  of  some  standing.  No  doubt  the  site  of  the 
affection  and  the  good  drainage  afforded  to  the  tubes  were 
responsible  for  this  immunity  from  symptoms. 


212  DISEASES   OF   THE  LUNGS   AND   PLEURA 

As  a  rule,  the  patient  is  not  so  fortunate,  and  symptoms 
manifest  themselves,  at  first  not  very  serious,  but  gradually 
becoming  more  urgent.     One  of  the  earliest  noticed  is  cough, 
v^ith  attendant  expectoration.     This  is  at  first  muco-purulent 
in   character,   and    not    great    in    amount.     As   the    disease 
advances,  the  cough  increases,  and  with  it  the  amount  of 
sputum,  until  at  last  large  quantities— a  pint  or  more  in  the 
twenty-four   hours — may  be   expectorated.     The   manner   of 
its  expulsion  is   often  characteristic.     The   patient   may   not 
expectorate  for  some  hours,  and  then  perhaps,  after  some 
movement  which  disturbs  the  contents  of  the  over-full  tubes, 
he    will    begin    to    cough,    and    with    more    or    less    violent 
paroxysms,   frequently  attended   with   retching,   will    rapidly 
bring  up  several  ounces.     We  have  even  seen  the  expectora- 
tion discharged  through  nose  as  well  as  mouth,  so  severe  and 
distressing  may  be  the  paroxysms.     Such  attacks  may  occur 
at  any  time,  but  are  most  frequently  observed  in  the  early 
morning,  on  first  waking,  the  secretion  having  accumulated 
in  the  tubes  during  the  hours  of  sleep. 

The  sputum,  though  becoming  more  abundant,  may 
for  long  remain  untainted;  but  sooner  or  later  it  be- 
comes foetid,  and  is  often  extremely  offensive.  Whiffs  of  foul 
gas  frequently  precede  and  attend  the  expectoration.  In 
a  case  recorded  by  Trousseau*  "the  smell  of  the  patient's 
breath  was  such  as  to  render  pestiferous  the  whole 
of  the  suite  of  rooms  occupied  by  him,  and  even  the 
staircase  leading  to  them  was  redolent  of  the  same  stench;" 
and  this  is  no  highly-coloured  description  of  what  is  some- 
times observed.  Although,  however,  the  foetor  of  the  sputa 
when  first  brought  up  may  be  so  great,  it  is  curiously 
evanescent,  owing  to  the  volatile  character  of  the  substance 
to  which  the  odour  is  due. 

If  placed  in  a  glass  and  allowed  to  stand  for  a  few  hours, 
the  sputum  will  be  found  to  resolve  itself  into  three  layers — 
an  upper  frothy  scum,  a  greenish  watery  layer,  and  at  the 
bottom  of  the  tube  a  grey  purulent  deposit,  containing  pus 
cells,  Charcot-Teyden  crystals,  crystals  of  fatty  acids,  together 
with  numerous  micro-organisms,  and  often  horribly  offensive 
small  yellowish  masses — the  so-called  "  Dittrich's  plugs." 

In  spite  of  the  distressing  symptoms,  the  general  health 
of  the  patient  long  remains  surprisingly  good.     The  features 


PLATE  XII 


PCLMOXAEV    OsTEO-ARTHROPATHV. 


To  face  p.  213. 


PULMONARY  OSTEO-ARTHROPATHY 

The  X-ray  photograph  of  the  right  arm  and  wrist  reveals  the 
layers  of  new  bone  which  are  formed  beneath  the  periosteum  in 
this  disease.  They  are  visible  on  the  shafts  of  the  lower  third 
of  the  radius  and  ulna,  and  along  the  shafts  of  the  metacarpal 
bones.  To  a  less  degree  they  were  also  present  on  the  first  and 
second  phalanges. 

From  a  male  patient,  G.  V.,  aged  thirty-one,  a  compositor,  the 
appearance  of  whose  hands  and  wrists  are  shown  in  Fig.  26. 
He  suffered  from  bronchiectasis  originating  in  chronic  bron- 
chitis, and  brought  up  as  much  as  197  ounces  of  offensive  sputum 
during  the  week.  ^Vhen  admitted  into  the  Brompton  Hospital 
in  1902,  the  right  lung  was  found  to  be  extensively  affected,  and 
the  left  to  some  extent  also  involved.  The  fingers  were  markedly 
clubbed,  and  the  lower  ends  of  both  forearms  and  of  both  legs 
above  the  ankles  v/ere  enlarged.  The  knee  and  ankle  joints  were 
somewhat  swollen  and  tender,  and  contained  fluid.  X-ray 
examination  showed  that  a  layer  of  new  bone  surrounded  the 
shafts  of  the  lov/er  third  of  the  radius  and  ulna,  and  of  the  tibia 
and  fibula  on  either  side,  and  was  also  present  on  the  metacarpals 
and  the  metatarsals,  and  to  a  less  extent  on  the  phalanges.  The 
sputum  was  examined  on  many  occasions  for  tubercle  bacilli,  but 
none  were  found.     There  was  no  evidence  or  history  of  syphilis. 

After  staying  eight  months  in  the  hospital,  he  left  but  little 
improved ;  but  shortly  afterv/ards  his  cough  and  expectoration 
abated  greatly,  and  when  seen  in  July,  1904,  he  was  only  bring- 
ing up  a  very  little  incffeni^ive  sputum.  The  enlargement  of  }ii ; 
bones  was  less  marked,  and  X-ray  examination  .showed  that  t'.:o 
deposits  of  nev/  bone  v;crc  thinne.-^  Ihov.jh  denjcr,  than  befcrr. 
lie  died  at  home  about  tv.o  venrs  ip.ter. 


PLATE  XII 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        213 

are  somewhat  puffed  and  suffused,  and  there  may  be  some 
slight  Hvidity  of  colouring  in  lips  and  cheeks,  the  fades  thus 
differing  much  from  that  often  presented  by  the  emaciated 
sufferer  from  tuberculosis.     For  some  time  there  may  be  no 
pyrexia,  and  except  for  a  little  dyspnoea  on  exertion  and  the 
foetor  of  the  breath  and  expectoration,  there  would  be  nothing 
to  prevent  the  patient  from  following  his  ordinary  avocation. 
At  this  stage  clubbing  of  the  fingers  and  toes  makes  its 
appearance,  and  in  certain  cases  also  a  bulbous  condition  of 
the  nose.     The  clubbing  sometimes  reaches  a  high  degree, 
and  becomes  a  point  of  some  importance  in  diagnosis,  though 
we  have  known  cases  of  bronchiectasis  in  which  it  has  been 
but  little  m^arked.   Signs  of  pulmonary  osteo -arthropathy  may 
also  in  some  cases  be  observed.     The  subperiosteal  deposition 
of    new   bone    is    chiefly   noticeable   in    the    neighbourhood 
of  the  wrists  and  ankles — the  forearms  and  legs,  also  the 
metacarpal  and  metatarsal  bones,  being  the  parts  commonly 
involved.      The   changes,   which  are   clearly  apparent  in  an 
X-ray  photograph  (Plate  XII.),  lead  to  an  enlargement  with 
some  tenderness  of  the  affected  areas  (Fig.  26).     Hemoptysis 
is  not  uncommon,  and  copious  and  even  fatal  attacks  have 
been  known  to  result  from  rupture  of  an  aneurism  of  a  branch 
of  the  pulmonary  artery  traversing  the  wall  of  the  ectasia. 

Such  are  the  symptoms  during  what  we  may  call  the  second 
stage  of  the  disease.  Sooner  or  later  constitutional  symptoms 
make  themselves  apparent  in  the  form  of  recurrent  attacks  of 
irregular  fever,  lasting  perhaps  a  fortnight  or  more,  and 
probably  produced  by  septic  absorption  from  the  foetid  con- 
tents of  the  dilated  tubes.  These  undermine  the  patient's 
strength,  but  he  rarely  wastes,  as  in  a  case  of  phthisis.  Finally 
the  end  is  ushered  in  by  the  advent  of  septic  broncho-pneu- 
monia, or  perhaps  by  the  onset  of  cerebral  (or  cerebellar) 
abscess.  So  well  known,  indeed,  is  the  occurrence  of  this 
latter  complication  that  it  should  be  a  rule  at  once  to  suspect 
It,  if  any  cerebral  symptoms  develope  in  a  patient  suffering 
from  bronchiectasis.  Septic  absorption  and  diffuse  general 
bronchitis  are  less  common  terminations  of  the  disease. 

In  cases  in  which  the  bronchial  dilatation  is  secondary  to 
pressure  or  contraction  of  a  main  air  tube,  the  expectoration 
IS  often  very  viscid  and  mucoid,  and  not  as  a  rule  foetid.  It  is 
expelled  with  considerable  difficulty  in  successive  thick  masses 


214 


DISEASES    OF   THE  LUNGS    AND    PLEURA 


after  violent  attacks  of  coughing,  at  such  times  as  there  shall 
have  been  sufficient  accumulation  to  force  the  narrowed 
passage. 


Fig.  26.— Photograph  showing  the  Marked  Clubbing  of  the  Fingers, 
AND  Enlargement  of  the  Wrists  and  Adjoining  Parts  character- 
istic OF  Pulmonary  Osteoarthropathy. 

(From  a  male  patient,  G.  V.,  aged  31,  who  suffered  from  bronchiectasis.) 

Physical  Signs.— These,  like  the  symptoms,  vary  in 
different  cases,  and  no  special  sign  can  be  said  to  be  pathog- 
nomonic of  the  malady. 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        21 5 

In  bronchitic  cases  we  may  find  at  first  merely  a  few  sharp 
and  persistent  clicks  at  the  base  of  one  lung.  As  the  disease 
progresses,  and  as  fibrosis  of  the  pulmonary  tissue  advances, 
the  note  over  this  region  becomes  gradually  flattened  and 
impaired,  and  the  chest  a  little  retracted.  Later  the  heart  is 
displaced  towards  the  affected  side.  Signs  of  a  cavity  will 
now  be  discovered — bronchial  breathing,  bronchophony,  and 
whispering  pectoriloquy — which  may  suggest  to  the  ear  a 
single  sacculated  cavity,  but  which  experience  recognises  as 
in  all  probability  significant  of  several  adjacent  dilated  tubes, 
with  intervening  lung  converted  into  fibrous  tissue.  The 
situation  of  these  signs  will  depend  on  the  position  of  the 
cavij;y,  but  they  are  often  best  heard  near  the  angle  of  the 
scapula  or  in  the  adjacent  region  of  the  axilla.  Sometimes 
the  "veiled  puff"  of  Skoda  may  be  heard,  in  which  the 
inspiratory  murmur,  at  first  indistinct,  becomes,  as  inspiration 
deepens,  suddenly  loud  and  bronchial.  It  is  probably  pro- 
duced by  the  sudden  removal  of  some  obstruction  in  the 
tube  communicating'  with  a  cavity,"  and  cannot  therefore  be 
regarded  as  pathognomonic  of  bronchiectasis. 

In  the  signs  themselves,  therefore,  there  is  nothing  peculiar, 
but  their  variability  and  the  way  in  which  they  alter,  being 
now  pronounced  and  now  obscured,  according  as  the  bronchi 
are  filled  or  empty,  is  a  point  which  should  be  noticed.  Such 
rapid  alteration,  if  observed,  would  strongly  suggest  bron- 
chiectasis, for  no  other  cavities  possess  such  facilities  for 
speedy  evacuation  and  refilling. 

In  cases  in  which  neighbouring  dilatations  have  coalesced, 
a  considerable  area  of  excavation  may  be  produced,  and  we 
have  even  known  almost  the  whole  of  the  lower  lobe  to  be 
converted  into  one  large,  evil-smelling  cavity.  In  such  cases 
cavernous  breath-sounds  and  gurgling  rales,  with  pec- 
toriloquy, may  be  distinctly  heard,  and  the  percussion  note 
acquires  a  perceptibly  tubular  character.  The  symptoms 
under  these  circumstances  become  more  severe  and  hectic, 
nutrition  suffers,  and  diarrhoea,  with  red  tongue,  is  observed. 
Elastic  tissue  is  now  to  be  found  in  the  sputum,  but  not 
tubercle  bacilli,  unless,  as  sometimes  happens,  there  be  an 
associated  tuberculous  infection. 

Duration  of  the  Disease. — Bronchiectasis,  owing  to  its 
anatomical  characters,  is  not  a  disease  from  which  we  may 


210  DISEASES   OF   THE  LUNGS   AND   PLEUR.^ 

expect  recovery.  At  the  best,  all  that  we  may  hope  for  is 
that,  by  preventing  decomposition  of  the  sputum,  we  may  be 
able  to  arrest  its  further  progress.  In  nearly  all  cases,  in 
spite  of  treatment,  the  disease  gradually  advances,  although 
its  duration  varies  much  in  different  individuals,  in  some  cases 
being  exceedingly  chronic,  in  others  running  a  comparatively 
acute  course. 

Diagnosis. — Basal  phthisis  may  sometimes  be  mistaken  for 
bronchiectasis,  especially  in  the  early  stages,  when  the  upper 
part  of  the  lung  is  not  yet  attacked.  Basal  phthisis,  however, 
is  rare;  nevertheless  its  occurrence  will  serve  to  remind  us 
that  no  case  can  be  diagnosed  with  certainty  as  one  of  bron- 
chiectasis unless  repeated  examinations  of  the  sputum  by  the 
most  careful  methods  have  proved  the  absence  of  tubercle 
bacilli.  It  will,  of  course,  be  borne  in  mind  that  tubercle  may 
become  engrafted  upon  bronchiectasis,  although  this  is 
uncommon. 

A  more  important  question  is  the  diagnosis  between  bron- 
chiectasis and  a  localised  einpyema  rupturing  into  a  bronchus. 
The  two  diseases  have  many  features  in  common,  and  the 
diagnosis  is  sometimes  a  matter  of  great  difficulty,  especially 
when  the  empyema  is  small  and  at  the  diaphragmatic  surface 
of  the  lung.  The  history  of  the  case  is  important,  especially 
the  gradual  appearance  and  laminated  character  of  the  expec- 
toration, in  contrast  with  its  sudden  and  purulent  outburst  in 
empyema.  A  normal  leucocyte  blood-count  will  point  strongly 
against  suppurative  pleurisy,  but  a  leucocytosis  is  of  less 
diagnostic  value,  being  sometimes  also  present  in  bronchiec- 
tasis. An  X-ray  examination  will  occasionally  indicate  the 
presence  of  one  or  more  cavities  at  the  base  of  the  affected 
lung,  and  thus  aid  in  diagnosis,  but  as  a  rule,  the  thickening 
of  the  lung  tissue  around  the  dilated  tubes  leads  to  the 
formation  of  a  general  basal  shadow,  which  is  in  no  way 
distinctive. 

As  we  have  already  indicated,  a  foreign  body  may  be  the 
cause  of  the  bronchiectasis.  A  patient  once  came  before  one 
of  us  in  the  outpatient  room  at  the  Brompton  Hospital  com- 
plaining of  cough  of  several  weeks'  duration.  Examination 
revealed  only  a  few  crepitations,  with  slightly  impaired  note 
at  one  base.  The  diagnosis  of  tubercle  or  bronchiectasis  was 
discussed,  but  before  the  former  could  be  finally  excluded  the 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        21/ 

patient  removed  all  doubt  as  to  the  nature  of  the  disease  by 
coughing  up  the  vertebra  of  a  rabbit.  Recovery  ensued.  The 
case  illustrates  the  necessity  of  remembering  the  possi- 
bility of  such  an  occurrence,  even  though  no  history  of  it  be 
volunteered. 

Treatment. — In  considering  the  treatment  of  bronchiec- 
tasis our  first  duty  is  to  exclude  as  far  as  possible  the  presence 
of  a  foreign  body.  If  there  be  the  slightest  reason  to  suspect 
this,  a  bronchoscopic  and  X-ray  examination  must  be  made, 
and  if  the  body  be  discovered  an  attempt  made  to  extract  it, 
which  will  often  be  successful.  This  subject  is  more  fully 
discussed  in  the  next  chapter.  When  the  foreign  body  is 
thus  early  removed,  recovery  or  great  amelioration  of 
symptoms  will  ensue. 

In  other  cases,  and  we  fear  they  are  the  great  majority, 
though  we  may  not  be  able  to  cure  the  disease,  yet  consider- 
able alleviation  can  at  least  be  given  to  the  patient  by 
appropriate  treatment. 

The  chief  symptom  of  which  complaint  is  made  is  the  offen- 
sive character  of  the  breath  and  of  the  sputum.  This  may  be 
best  combated  by  means  of  the  creosote  vapour  bath,  origin- 
ally suggested  by  Dr.  Arnold  Chaplin."  To  carry  out  this 
treatment  a  bare  room  is  required,  with  a  concrete  floor  if 
possible,  and  without  any  furniture  or  hangings  which  would 
be  damaged  by  the  creosote  vapour.  On  the  floor  stands 
an  iron  tripod,  supporting  a  metal  dish  or  pan,  into  which 
commercial  creosote  is  poured.  Under  the  dish  a  Bunsen 
burner  or  spirit-lamp  is  placed  for  the  purpose  of  volatilising 
the  creosote,  care  being  taken  not  to  use  too  strong  a  flame, 
lest  the  creosote  catch  light.  Should  this  accident  occur,  the 
flame  may  easily  be  put  out  by  means  of  a  little  sand,  which 
it  is  well  to  keep  always  in  readiness.  Both  tripod  and  spirit- 
lamp  are  best  placed  on  a  metal  tray,  in  case  the  evaporating 
dish  should  be  overturned.  When  all  is  ready,  the  patient 
enters  the  room.  He  should  be  clad  in  a  linen  overall,  and 
should  be  provided  with  a  piece  of  lint  or  a  handkerchief  to 
protect  his  eyes.  The  Bunsen  burner  is  then  lit,  and  the 
fumes  of  the  creosote  begin  to  rise.  The  irritating  effect  of 
the  vapour  is  soon  felt  by  the  patient,  who  commences  to 
cough,  and  in  this  way  succeeds  in  bringing  up  a  large  quan- 
tity of  phlegm,  to  a  great  extent  emptying  his  tubes.     The 


2l8  DISEASES  OF  THE  LUNGS  AND  PLEUH/E 

special  action  of  the  creosote  now  comes  into  play,  the  vapour 
being  enabled  to  reach  and  act  upon  areas  of  the  bronchial 
tract,  which,  having  been  freed  from  secretion,  are  in  a  con- 
dition to  benefit  by  the  cleansing  property  of  the  antiseptic. 

Treatment  should  be  commenced  by  a  "bath"  every  other 
day,  the  patient  remaining  in  the  vapour  for  a  few  minutes 
only.  Very  soon  a  daily  bath  may  be  given  of  half  an  hour's 
duration,  or  longer,  for  a  course  of  five  or  six  weeks,  and 
afterwards  at  gradually  increasing  intervals. 

As  a  result  of  this  treatment  it  is  often  found  that  a  very 
sensible  diminution  in  the  foetor  of  the  sputum  results,  while 
sometimes  the  odour  entirely  disappears.  Hand-in-hand  with 
the  improvement,  a  progressive  diminution  in  the  amount  of 
the  sputum  may  be  observed,  as  in  an  instructive  case 
recorded  by  Sir  J.  Kingston  Fowler."  In  other  cases,  though 
the  fcetor  may  diminish  or  disappear,  the  quantity  of  sputum 
remains  the  same.  In  others,  again,  the  treatment  seems 
to  fail. 

Should  it  not  be  found  possible  to  commence  the  creosote 
baths  at  once,  we  would  recommend  as  a  palliative  the  use  of 
some  antiseptic  inhalation,  given  in  a  Coghill's  respirator.  The 
following-  formula,  long  in  use  at  St.  Bartholomew's  Hospital, 
is  a  useful  one  :  Creosoti,  tincturse  iodimitis,  acidi  carbolici, 
astheris,  and  spiritus  vini  rectificati,  aa  3i.  The  inhalation  may 
be  practised  several  times  a  day,  and  often  does  good  in 
diminishing  foetor  of  the  sputum. 

Many  cases  of  bronchiectasis  can  be  kept  fairly  drained  for 
years  by  the  simple  expedient  of  devoting  half  an  hour  two  or 
three  times  a  day  to  expectoration,  by  leaning  over  with  head 
low,  so  as  to  allow  any  accumulated  fluid  to  gravitate  towards 
the  area  of  glottic  sensitiveness. 

Internally,  the  administration  of  creosote,  or  of  such  drugs 
as  turpentine,  oil  of  sandal  wood,  and  copaiba,  the  volatile 
oils  of  which  are  excreted  by  the  bronchial  mucous  mem- 
brane, does  some  good,  but  the  amelioration  produced  is  com- 
paratively slight.  We  have  in  some  cases  prescribed  with 
advantage  garlic,  either  the  clove  itself  or  the  Syrupus  Allii 
Aceticus,  as  suggested  by  the  late  Dr.  Vivian  Poore.'^  Some 
patients  bear  the  drug  well,  but  others  resent  the  penetrating 
odour  of  garlic  which  becomes  imparted  to  the  breath. 

Another  plan  of  treatment,  recommended  by  the  late  Sir  T. 


NARROWING    AND    DILATATION    OF   THE   BRONCHI        2ig 

Grainger  Stewart,"  Mr.  Colin  Campbell/*  and  others,  con- 
sists in  injecting-  various  solutions  into  the  trachea  through 
the  larynx  by  means  of  a  special  syringe.  The  following 
formula  was  used  by  Grainger  Stewart'^  for  such  intra- 
laryngeal  injections : 

Menthol  ...     lo  parts. 

Guaiacol  ...         ...         ...         ...         ...         ...         ...       2      ,, 

Olive  oil  88      „ 

One  drachm  to  be  injected  once  or  twice  daily. 

We  have  tried  this  and  other  solutions,  and  have  found 
benefit  to  result  in  certain  cases,  the  fcetor  of  the  sputum  sen- 
sibly diminishing  under  the  treatment.  A  little  practice  will 
enable  the  operator  to  guide  the  syringe  over  the  epiglottis 
and  through  the  vocal  cords  before  making  the  injection. 

Should  the  excessive  quantity  of  the  sputum  be  a  source 
of  trouble  and  annoyance  to  the  patient,  an  attempt  may  be 
made  to  lessen  it  by  diminishing  the  daily  quantity  of  liquid 
taken. 

In  some  cases,  where  the  absence  of  adhesions  permits  it, 
the  performance  of  an  artificial  pneumothorax,  and  the  com- 
pression of  the  lung  by  the  introduction  of  nitrogen,  as 
described  in  a  later  chapter,  gives  considerable  relief.  In  this 
way  the  bronchi  are  compressed,  and  the  accumulation  of 
secretion  and  the  absorption  of  toxines  prevented.  The  rehef 
is,  however,  not  permanent,  and  can  only  be  maintained  by 
keeping  up  the  positive  pressure  by  the  reintroduction  of 
nitrogen  at  intervals  varying  from  two  to  four  weeks.  Never- 
theless, as  a  means  of  giving  temporary  relief,  the  method 
deserves  consideration. 

Surgical  Treatment. — The  condition  of  a  patient  suifering 
from  bronchiectasis  is  sometimes  so  pitiable  that  it  is  not 
surprising  that  attempts  have  been  made  to  give  relief  by  sur- 
gical intervention. 

Opening  and  draining  of  the  cavity  was  first  attempted, 
especially  in  cases  in  which  the  signs  apparently  pointed  to  a 
single  large  cavity  at  the  base  of  the  lung.  In  performing  the 
operation,  which  is  carried  out  as  when  dealing  with  a  pul- 
monary abscess  (see  p.  361),  it  must  be  remembered  that  not 
infrequently,  even  in  severe  cases  of  bronchiectasis,  the  pleural 
layers  are  not  adherent  over  the  affected  portion  of  the  lung. 
Accordingly,  after  resection  of  ribs,  and  before  opening  the 


220  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

pleura,  the  visceral  and  parietal  layers  must  be  stitched 
together,  thus  minimising  the  risk  of  infecting  the  pleural 
cavity  when  the  lung  is  incised. 

Experience,  however,  showed  that  it  is  quite  rare  for  a 
single  cavity  to  be  present,  and  that  several  bronchi  are,  as  a 
rule,  dilated,  so  that  drainage  of  one  can  hardly  be  expected  to 
effect  a  cure.  Nevertheless,  one  or  two  successful  cases  have 
been  recorded^^  in  which  complete  recovery  has  resulted,  and 
in  others  a  certain  amount  of  relief — albeit  temporary  in  char- 
acter— has  been  given.  As  a  result  of  the  operation  the 
amount  of  sputum  diminishes,  the  cough  becomes  less  harass- 
ing, and  fever,  if  present,  tends  to  subside.  Thus,  in  a  case 
which  occurred  in  the  practice  of  one  of  us^*^ — the  first,  we 
believe,  of  the  kind  in  which  the  operation  was  performed— it 
was  very  striking  to  note  the  extraordinary  effect  upon  the 
cough  and  expectoration  brought  about  by  draining  the 
cavity.  Although  the  amount  of  discharge  through  the  drain- 
age-tube did  not  exceed  two  ounces,  the  expectoration,  which 
had  previously  amounted  to  sixteen  or  twenty  ounces  per  diem, 
was  reduced  to  almost  nothing,  proving  how  much  of  it  must 
have  been  secreted  by  the  ascending  bronchial  tract,  in 
response  to  the  irritation  produced  by  the  passage  over  it  of 
the  offensive  discharge  from  the  dilated  portion  of  the  tubes. 
But  the  relief  obtained  is,  unhappily,  often  but  temporary;  the 
other  dilated  and  undrained  bronchi  tend  still  further  to 
enlarge,  the  offensive  sputum  again  increases,  and  the  old 
symptoms  recur. 

More  recently  attempts  have  been  made  to  secure  adequate 
collapse  of  the  lung  and  diminution  in  size  of  the  dilated 
tubes  by  means  of  a  more  or  less  extensive  resection  of  ribs, 
while  leaving  the  pleura  intact.  The  soft  parts  then  come  to 
form  the  covering  of  the  chest  wall  and  the  lung  falls  in.  We 
have  seen  the  operation  successful,  and  the  patient's  symptoms 
greatly  improved,  but  the  procedure  is  not  free  from  risk,  and 
we  have  known  a  fatal  result  to  follow.  Moreover,  great 
deformity  of  chest  results,  though  this  may  be  to  a  large 
extent  hidden  by  a  properly  adjusted  support. 

Another  operation  sometimes  performed  in  these  cases, 
especially  when  the  disease  is  not  limited  to  the  lower  lobe, 
is  that  of  "rib  mobilisation"  as  devised  by  Wilms.  This  con- 
sists in  the  removal  of  one  to  two  inches  of  the  posterior  por- 


NARROWING  AND   DILATATION   OF   THE   BRONCHI        221 

tion  of  the  ribs  from  the  first  to  the  ninth  or  tenth  inclusive, 
and,  at  a  later  stage,  a  similar  length  of  the  first  five  to  seven 
costal  cartilages  anteriorly.  To  diminish  shock,  an  interval  of 
a  few  weeks  should  be  allowed  between  the  operations.  As  a 
result  the  side  of  the  chest  falls  in,  the  dilated  bronchi  col- 
lapse, and  the  symptoms,  especially  the  cough  and  offensive 
sputum,  are  greatly  amehorated.  A  successful  case  of  this 
kind  was  shown  at  the  Clinical  Section  of  the  Royal  Society 
of  Medicine  in  1915  by  Mr.  Morriston  Davies."  But  here 
again  the  procedure  is  not  free  from  risk.  Neither  form  of 
operation  should,  therefore,  be  undertaken  without  the  most 
careful  consideration,  but  if  the  patient's  life  is  rendered 
burdensome  to  him  by  the  quantity  of  foul  expectoration 
brought  up  by  incessant  attacks  of  coughing,  then  an  opera- 
tion on  the  lines  indicated  should  be  seriously  entertained. 


REFERENCES. 

^  "  Destructive  Pneumonia  due  to  Compression  of  Bronchus  by  Aneurism 
of  Aorta,"  by  J.  Pearson  Irvine,  M.D.,  Transactions  of  the  Pathological 
Society  of  London,  1877-78,  vol.  xxix.,  p.  36. 

-  "  The  Bradshaw  Lecture  on  the  Results  of  Bronchial  Obstruction,"  by 
G.  Newton  Pitt,  M.D.,  F.R.C.P.,  British  Medical  Journal,  1910,  vol.  ii., 
p.  1845. 

^  "  On  Destructive  Changes  in  the  Lung  from  Diseases  in  the  Medi- 
astinum invading  or  compressing  the  Pneumogastric  Nerves  and  Pulmonary 
Plexus,"  by  William  Gull,  M.D.,  Guy'' s  Hosfital  Re-ports,  third  series,  1859, 
vol.  v.,  p.  307. 

*  "  Bronchiectasis  :  a  Clinical  Study,"  by  Theodore  Dyke  Acland,  M.D., 
F.R.C.P.,  The  Practitioner,  London,  April,   1902,  Old  Series,  vol.  Ixviii., 

P-  379- 

*  Re-port  on  the  Work  of  the  Pathological  Department  of  the  Brompton 
Hospital  during  the  Three  Years,  April,  1900,  to  April,  1903,  by  P.  Horton- 
Smith  (Hartley),  M.D.,  Table  viii.,  p.  33.     London,  1903. 

°  {a)  The  Diseases  of  the  Lungs,  by  J.  Kingston  Fowler,  M.D.,  F.R.C.P., 
and  Rickman  John  Godlee,  M.S.,  F.R.C.S.,  p.   126.     London,   189S. 
{b)  Loc.  cit.,  p.  139. 

'  "A  Pedunculated  Intrabronchial  Tumour  (Sarcoma)  causing  Bron- 
chiectasis," by  J.  A.  Braxton  Hicks,  M.D.,  Proceedings  of  the  Royal 
Society  of  Medicine  [Medical  Section),  vol.  vii.,  pt.  2,  p.   189,  1914. 

*  "  Acute  Bronchiectasis,"  by  Seymour  J.  Sharkey,  M.D.,  St.  Thomas''s 
Hospital  Reports,  New  Series,  1892,  vol.  xxii.,  p.  33. 

"  Lectures  on  Clinical  Medicine,  by  A.  Trousseau,  New  Sydenham 
Society  edition,  vol,  iii.,  p.  124.     London,  1870. 


222  DISEASES    OF   THE   LUNGS   AND   PLEUR.E 

"  Auscultation  and  Percussion,  by  Samuel  Gee,  M.D.,  sixth  edition, 
p.  105.     London,  1908. 

"  "Remarks  on  the  Treatment  of  Foetid  Expectoration  by  the  Vapour 
of  Coal-Tar  Creasote,"  by  Arnold  Chaplin,  M.D.,  British  Medical  Jotirnal, 
1895,  vol.  i.,  p.  1371. 

^2  Nervous  Affections  of  the  Hand,  and  Other  Clinical  Studies,  by  George 
Vivian  Poore,  M.D.,  p.  276.     London,  1897. 

"  "  On  the  Treatment  of  Bronchiectasis,"  by  T.  Grainger  Stewart,  M.D., 
British  Medical  Journal,  1893,  vol.  i.,  p.   1147. 

"  (i)  "  The  Treatment  of  Respiratory  Affections  by  Means  of  Large 
Medicinal  Injections  through  the  Larynx,"  by  Colin  Campbell, 
M.R.C.S.,  Transactions  of  the  Royal  Medical  and  Chirurgical 
Society,  1895,  vol.  Ixxviii.,  p.  39.  For  a  discussion  upon  the 
paper,  see  British  Medical  Journal,  1894,  vol.  ii.,  p.  1238. 
(2)  "  The  Treatment  of  Phthisis  by  Intratracheal  Injection  of  Large 
Quantities  of  Izal,"  by  Colin  Campbell,  M.R.C.S.,  Transactions  of 
the  British  Congress  on  Tuberculosis,  vol.  iii.,  p.  406.  London, 
1902. 

'°  (i)  "  Two  Cases  of  Bronchiectasis  treated  by  Paracentesis,  with 
Remarks  on  the  Mode  of  Operation,"  by  C.  Theodore  Williams, 
M.D.,  and  Rickman  J.  Godlee,  M.S.,  F.R.C.S.,  Transactions  of  the 
Royal  Medical  and  Chirurgical  Society,  1886,  vol.  Ixix.,  p.  317. 
(2)  The  Diseases  of  the  Lungs,  by  James  Kingston  Fowler,  M.D., 
F.R.C.P.,  and  Rickman  John  Godlee,  M.S.,  F.R.C.S.,  p.  422. 
London,  1898. 

'^  "  On  a  Case  of  Basic  Cavity  of  the  Lung  Treated  by  Paracentesis," 
by  R.  Douglas  Powell,  M.D.,  and  R.  W.  Lyell,  F.R.C.S.,  Transactions  of 
the  Royal  Medical  and  Chirurgical  Society,  1880,  vol.  Ixiii.,  p.  '>)Z?>- 

'"  [a)    "  Bronchiectasis   treated  by   Rib    Mobilisation    (Wilms),"   by    H. 
Morriston    Davies,    M.C.,    Proceedings    of    the    Royal    Society    of 
Medicine  {Clinical  Section),  vol.  viii.,  p.   -i,-^,   1915.     See  also — 
{b)  "  Surgery   of   the  Lung    and   Pleura,"   by   H.    Morriston   Davies, 
M.A.,  M.D.,  M.C.,  F.R.C.S.,  p.  208.     London,  1919.     ■ 


CHAPTER  XIV 

ON    FOREIGN    BODIES    IN    THE    AIR-PASSAGES,    AND 
ESPECIALLY   IN    THE    BRONCHI 

Although  nothing  of  a  definite  kind  appears  to  have  been 
written  upon  the  subject  of  foreign  bodies  in  the  air-passages 
at  an  earHer  period  than  the  end  of  the  sixteenth  century,  there 
are  indications  in  literature  that  the  occurrence  was  not 
unknown  to  ancient  observers.  And  doubtless  particles  of 
food  have  "  gone  the  wrong  way "  occasionally,  since  the 
earhest  times,  from  careless  eating-,  under  conditions  of  mental 
excitement,  or  in  paralysis  of  the  larynx.  The  ordeal  by 
eating  of  consecrated  bread,  which  obtained  in  this  country  in 
the  early  Middle  Ages,  and  the  allied  mystical  trials  prevalent 
in  Eastern  countries  many  centuries  before,  probably  had  their 
real  basis  in  that  dryness  of  mouth  and  irregular  action  of  the 
muscles  of  deglutition  and  respiration  produced  by  excite- 
ment, which  favour  the  occurrence  of  choking  attacks  from 
intrusion  of  food  into  the  larynx.  The  death  of  Earl  Godwin 
has  in  fiction  been  attributed  to  this  cause.^ 

More  strictly  within  the  cognisance  of  medical  history, 
observations  of  this  accident  were  recorded  by  writers  at  the 
end  of  the  sixteenth  and  in  the  seventeenth  centuries,  and  in 
1644  tracheotomy  was  first  definitely  advocated^"  for  the 
removal  of  foreign  bodies  from  the  air-passages,  although  the 
operation  appears  not  to  have  been  actually  performed  for 
this  purpose  until  fifty  years  later. 

The  literature  of  this  limited  subject  is  vast,  and  the  cases 
quoted  are  innumerable,  involving  much  repetition.  No  such 
admirable  exposition  of  the  main  symptoms  and  signs  of 
tracheo-bronchial  obstruction  has  appeared  since  that  by 
Stokes*  in  his  work  on  Diseases  of  the  Chest,  published 
in  1837. 

223 


224  DISEASES   OF   THE  LUNGS   AND   PLEURA 

etiology. — The  circumstances  under  which  foreign  bodies 
obtain  access  to  the  larynx  are  simple  enough.  Such  acci- 
dents are  common  in  children  with  their  ancestral  tendency 
to  use  the  mouth  as  a  prehensile  organ,  and  are  met 
with  even  in  adults  in  eating.  Thus,  a  boy  play- 
ing with  a  pea-shooter  inhales  one  of  the  peas  into  his 
larynx;  a  farm-hand,  holding  a  stalk  of  barley  or  bearded 
wheat  between  his  teeth,  has  his  attention  distracted,  and 
the  object  passing  into  his  mouth  is  propelled  back- 
wards to  the  fauces  by  the  action  of  the  tongue  upon 
its  salient  bristles  and  becomes  inhaled  into  the  larynx; 
a  workman,  whilst  eating  rabbit-pie  or  Irish  stew,  talks  or 
laughs,  and  a  fragment  of  bone  readily  slips  "  the  wrong  way." 
Again,  a  man  smoking  a  pipe,  whilst  riding  a  bicycle  or  on 
horseback,  may  in  a  sudden  fall  from  an  accident,  or  in  an 
epileptic  or  syncopal  attack,  break  the  stem  in  his  mouth,  and 
inhale  it  into  his  larynx.  Such  are  some  of  the  many  inci- 
dents that  have  actually  resulted  in  the  intrusion  of  a  foreign 
body  into  the  larynx.  Such  accidents  occur  through  mere 
carelessness  or  frolic,  or  under  any  conditions  leading  to 
sudden  inspiration  whilst  the  mouth  is  occupied  and  the 
patient  off  guard,  as  in  laughing,  coughing,  receiving  a 
sudden  blow  on  the  back,  and  the  like.  They  may  occur  also 
through  impaired  sensibility  of  the  protecting  laryngeal  aper- 
ture, be  it  during  the  temporary  insensibility  of  deep  sleep, 
anaesthesia,  or  epileptic,  apoplectic  or  syncopal  attacks. 
Dental,  pharyngeal  and  nasal  operations  under  anaesthesia  are 
not  uncommon  sources  of  this  accident — a  tooth,  a  septic 
portion  of  membrane  or  growth,  or  a  pledget  of  lint, 
besides  blood  and  other  fluids,  thus  obtaining  entry  to  the 
larynx. 

In  cases  of  ulcerative  destruction  of  the  epiglottis  or  larynx, 
foreign  material,  and  especially  fluids,  readily  obtain  access  to 
the  trachea;  and  a  similar  accident  may  also  occur  in  paralysis 
of  the  glottic  appendages,  as  from  diphtheria,  bulbar  paralysis, 
and  advanced  cerebro-spinal  lesions. 

Liquids  in  the  form  of  drinks,  corrosive  fluids,  pus,  blood, 
tuberculous  matters  or  portions  of  growth,  may  thus  pene- 
trate through  the  larynx  to  the  bronchi  and  lungs.  Corrosive 
fluids,  hoAvever,  rarely  penetrate  beyond  the  larynx,  where 
they  set  up  at  first  acute  spasm  and  then  inflammatory  oedema, 


ON  FOREIGN   BODIES    IN   THE   AIR-PASSAGES  225 

which  Speedily  produces  suffocation,  unless  relieved  by 
tracheotomy.  A  septic  broncho-pneumonia  or  bronchitis  not 
infrequently  results  from  the  inhalation  of  fluids,  be  they  gas- 
tric, sanguineous,  or  purulent. 

Except  in  an  academic  sense,  and  for  the  purpose  of  com- 
plete classification,  the  occurrences  attendant  upon  the  recep- 
tion of  liquids  into  the  larynx  are  scarcely  within  the  scope 
of  our  subject,  and  may  therefore  be  dismissed  without  fur- 
ther comment.  We  may  dismiss,  too,  with  a  bare  mention, 
those  uncommon  cases  in  which  matters  foreign  to  the  air- 
passages  are  introduced  into  the  tubes  from  below  the  glottis 
by  ulceration  from  neighbouring  parts;  for  example,  the  rup- 
ture of  suppurating  tuberculous  bronchial  glands  into  the 
upper  air-passages,  leading  to  the  intrusion  into  them  of 
caseous  or  cretaceous  tuberculous  masses.  The  rupture  of 
abscess  or  hydatid  of  the  lung,  pleura,  or  neighbouring  parts, 
or  the  bursting  of  an  aneurism  into  the  bronchial  tracts,  may 
also  be  simply  mentioned. 

Our  chief  concern  is  with  the  intrusion  through  the  glottis 
of  extraneous  and  more  or  less  solid  bodies.  We  cannot 
classify  these  foreign  bodies  better  than  after  the  manner 
adopted  by  Dr.  Hoffmann,*''  and  in  the  table  on  p.  226  we  have 
ventured  to  summarise  under  the  same  headings  an  analysis 
of  the  cases  from  his  tables  and  from  the  supplementary  one 
of  Dr.  Musser,  of  which  sufficient  details  are  given  with 
regard  to  certain  points  of  special  interest.  It  will  be  noted 
that  the  table  does  not  show  the  result  of  the  modern  method 
of  treatment  by  bronchoscopy,  but,  on  the  contrary,  the  mor- 
tality among  cases  operated  upon  and  not  operated  upon 
before  its  introduction. 

A  further  group  might  be  added  to  those  mentioned,  which 
would  include  living  bodies,  such  as  Ascaris  lunibricoides, 
leeches,  small  fish,  etc.,  which  have  in  rare  instances  found 
access  to  the  air-passages. 

From  a  consideration  of  the  data  to  which  we  have  referred 
certain  interesting  conclusions  may  be  drawn : 

Age. — The  accident  is  more  common  in  children  and  young 
people.  Thus,  of  the  210  cases  tabulated,  140  occurred  under 
twenty  years  of  age,  of  which  68  were  under  five  years. 

Sex. — The  male  sex  predominates.  Of  177  cases  in  which 
the  sex  is  mentioned,  118  were  males  and  59  females. 

15 


226 


DISEASES   OF   THE  LUNGS   AND   PLEUR/^. 


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Class      1.  :       Smooth 
round      pieces       of 
metal  or  glass  (coins, 
bullets,  etc.) 

Class    II.  :    Hard,    ir- 
regular,  sharp,    and 
pointed       objects 
(needles,      bones, 
splinters,  etc.) 

Class  III. :  Soft,  rough 
bodies      (heads      of 
grain,  etc.) 

Class  IV. :  Bodies  that 
swell  in  water  (fruit- 
seeds,  beans,  etc.) 

Class  V.  :  Hard  fruit- 
seeds    that    do    not 
swell  in  water  (plum- 
stones,  etc  ) 

Total 

ON  FOREIGN  BODIES   IN  THE  AIR-PASSAGES  22/ 

Position  of  the  Foreign  Body. — Of  the  210  cases  tabulated, 
the  foreign  body  occupied  the  trachea  in  21,  and  the  larynx  in 
7.  In  the  remaining  182  it  had  passed  beyond  the  trachea 
into  one  of  the  bronchi.  The  substance  may  be  impacted  in 
the  glottis,  or  in  the  ventricles  of  the  larynx,  or  in  the  sub- 
glottic space,  and  in  some  cases  in  which  it  has  passed  down- 
wards into  the  bronchus  it  has  been  projected  from  below 
again  into  the  glottis.  Having  reached  the  trachea,  the  body 
may  be  fixed  or  movable  there,  and  in  the  latter  case  a  par- 
ticular sign  audible  on  auscultating  the  larynx  and  trachea — 
the  bruit  de  grelottement  ou  de  soiipape — has  been  described 
as  produced  by  the  friction  of  the  foreign  body  against  the 
glottis  and  sides  of  the  trachea.'*  It  is  a  vibratile  sound,  com- 
parable in  some  cases  to  that  produced  by  the  sudden  applica- 
tion of  the  plug  (soupape)  to  the  upper  orifice  of  a  water-pipe. 

Of  the  130  cases  in  the  above  table  in  which  definite 
information  is  given,  in  70  the  body  entered  the  right 
bronchus,  in  60  the  left.  And  this  is,  perhaps,  not  far  from 
the  true  proportion,  although  it  has  generally  been  believed, 
for  the  reasons  first  given  by  Stokes,  that  the  predominance 
in  favour  of  the  right  bronchus  was  greater,  the  chief  reasons 
being  the  somewhat  wider  lumen  of  the  right  bronchus,  its 
more  vertical  direction,  and  the  greater  aspiratory  power 
attributed  to  the  right  lung.  Stokes  further  pointed  out  that 
"the  projection  or  septum  dividing  the  right  and  left  bronchi 
is  not  in  the  mesial  line,  but  decidedly  to  the  left  of  it,  so  that 
a  body  passing  through  the  glottis  will  be  thus  directed  into 
the  right  bronchus."^ 

Pathology. — The  changes  in  situ  wrought  by  the  foreign 
body  vary  with  its  shape  and  texture.  If  soft  and  smooth, 
it  may  produce  no  immediate  consequence;  if  hard,  rough  or 
pointed,  such  as  fragments  of  bone,  glass  or  metal,  a  certain 
degree  of  scarification  of  the  membrane  is  caused,  and  often 
immediate  capillary  haemorrhage  or  contusion,  with  speedy 
ulceration,  will  ensue.  Again,  the  condition  of  the  body, 
whether  clean,  foul,  or  septic,  will  much  influence  its  irritant 
effects. 

Bodies  that  remain  within  the  precincts  of  the  larynx  or 
trachea  cause  so  much  dyspnoea  and  spasm  of  the  glottis  that 
their  speedy  removal  or  the  death  of  the  patient  generally 
prevents    further   local    pathological    change.      Where    they 


228  DISEASES    OF   THE  LUNGS   AND   PLEURA 

penetrate  into  the  comparatively  insentient  lumen  of  the 
bronchus,  they  may  for  long  remain  undisturbed.  Under 
these  circumstances,  it  is  not  common  for  the  lumen  of  the 
tube  to  be  completely  occupied;  the  body  generally  becomes 
attached  to  one  side,  and  by  its  pressure  and  irritation  sets  up 
some  superficial  ulceration,  in  the  depression  of  which, 
covered  by  tenacious  mucus,  it  nestles. 

The  further  and  most  important  changes  brought  about 
by  the  presence  of  the  foreign  body  occur,  first,  in  the  lung 
territory  of  distribution  of  the  affected  bronchus;  secondly,  in 
the  pleura  and  in  other  parts  of  the  same  and  the  opposite 
lung;  and,  thirdly,  through  septic  poisoning  and  embolic 
infarction  in  other  parts  and  organs  of  the  body.  These  later 
effects  of  impaction,  which,  however,  commence  very  soon, 
are  the  result  of  the  partial  (or  complete)  obstruction  of  the 
bronchus,  retention  of  bronchial  secretions,  and  their  con- 
tamination by  septic  organisms.  In  this  way  bronchitis,  peri- 
bronchitis, bronchiectasis,  fibrous  inflammation  of  the  lung, 
and  other  consequences,  ensue. 

The  characteristic  sequel  to  an  obstructed  bronchus  is 
bronchiectasis,  but  there  is  this  peculiarity  in  the  change  fol- 
lowing upon  the  reception  of  a  foreign  body,  that  the  bron- 
chiectasis so  originating  at  once  becomes  foetid.  This  is  not 
the  case  with  a  bronchiectasis  that  results  from  partial  or 
complete  occlusion  by  a  living  tissue,  as  from  the  pressure  of 
an  aneurism  or  the  intrusion  of  a  growth,  provided,  of  course, 
that  no  ulceration  or  sloughing  at  the  constricted  part  follows 
upon  the  local  pressure.  The  fact  is  that  a  foreign  body  is 
either  septic  from  the  first  or  very  soon  becomes  so.  It  then 
constitutes  a  focus  of  septic  irritation;  the  mucous  secre- 
tions that  are  poured  out  become  contaminated  and  purulent, 
and  the  contamination  spreads  downwards  through  the  bron- 
chial tract.  Further,  owing  to  the  obstruction  to  the  lumen 
of  the  bronchus,  although  it  be  but  partial,  the  bronchial 
secretions  beyond  can  never  be  completely  expelled,  and  a 
fermenting  residue  remains.  The  result  is  analogous  to  that 
which  occurs  in  the  urinary  bladder  when  the  outflow  is  par- 
tially obstructed.  A  septic  bronchitis  is  thus  produced,  with 
hyperplasia  of  the  submucosa  and  peribronchitis;  the  tubes 
completely  lose  their  tonicity,  and  passive  dilatation  follows. 
The  trouble  then  extends  to  the  lung,  to  its  alveoli  and  connec- 


ON  FOREIGN   BODIES    IN   THE   AIR-PASSAGES  229 

tive  tissue,  spreading  from  the  bronchial  sheaths.  Chronic 
inflammation  and  pulmonary  fibrosis  result,  causing  a  shrink- 
ing of  the  lung  texture,  and  a  further  widening  through  trac- 
tion of  the  tubes.  The  rending  effects  of  coughing  may  have 
something  to  do  with  the  dilatation  of  the  tubes  in  those  cases 
in  which  the  obstruction  is  incomplete.  In  some  cases  an 
acute  pneumonia  may  supervene  at  an  early  date,  but  this  is 
rare,  except  when  tracheotomy  and  exploration  of  the  bron- 
chus have  been  practised. 

The  subsequent  phenomena,  such  as  pleurisy,  broncho- 
pneumonia, empyema  and  pulmonary  abscess,  which  fre- 
quently supervene,  are  of  septic  origin.  In  cases  which  run 
their  course  unrelieved,  it  is  common  for  one  or  more  of  the 
bronchial  dilatations  to  ulcerate,  producing  pulmonary  cavita- 
tion; and  in  some  instances  a  fistulous  tract  will  be  found  to 
extend  from  one  of  such  cavities  to  the  surface  of  the  lung, 
leading  to  empyema  or  possibly  to  pyopneumothorax,  or,  if 
the  pleura  be  adherent,  penetrating  to  the  costal  parietes  and 
there  producing  an  abscess.  Such  a  fistula  is  pathologically 
identical  with  those  which  in  other  regions  lead  from  bony 
or  other  necrotic  sequestra. 

Lastly,  the  superior  portions  of  the  same  lung,  and  later 
the  opposite  lung,  become  involved  in  a  greater  or  less  degree 
of  bronchiectasis,  and  in  broncho-pneumonic  changes  of  a 
septic  origin,  due  on  the  one  hand  to  extension  of  the  morbid 
processes,  and  on  the  other  to  inhalation  of  morbid  products. 
Clots  from  thrombosed  and  contaminated  veins  may  become 
detached  and  conveyed  to  distant  parts  as  septic  emboli,  and 
abscess  of  the  brain  from  this  cause  is  a  not  very  rare  sequel. 

Symptoms. — The  relation  of  a  case,  which  occurred  before 
the  introduction  of  bronchoscopy,  and  which,  from  the  diffi- 
culty, if  not  impracticability,  of  treating  it,  ran  its  course  to 
the  end,  will  perhaps  be  the  most  interesting  way  of  bringing 
together  the  main  symptomatic  features  of  this  grave  malady. 

Mr.  T.  S.,  aged  fifty-one,  a  dark,  pale  man  of  slender  build,  in 
practice  as  a  dentist,  had  been  under  observation  in  1900  for  an 
attack  of  renal  colic  which  had  not  recurred.  At  11.30  p.m.  on 
November  29,  1901,  a  cold,  foggy  night,  he  was  eating  some  Irish 
stew  at  his  home  in  Bromley,  when  he  felt  a  piece  of  bone  go  "  the 
wrong  way."  He  was  seized  with  severe  choking  dyspnoea,  and  at 
once  rushed  out,  without  extra  wrap,  to  a  neighbour,  Dr.  Ilott,  who 


230  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

found  him  livid  and  aphonic.  An  examination  of  the  pharynx  with 
eye  and  finger  revealed  nothing.  A  probang  was  passed  down  the 
oesophagus,  after  which  he  said  he  felt  relieved  and  went  home,  and 
Dr.  Ilott  did  not  see  him  again  for  some  months. 

When  seen  by  Sir  R.  Douglas  Powell  within  a  few  weeks  of  this 
occurrence,  he  complained  of  a  cough,  not  attended  with  any  special 
characters,  which  he  dated  from  his  accident.  No  physical  signs  could 
be  detected,  except  some  relative  feebleness  of  respiratory  sounds 
over  the  right  scapular  region,  and  he  was  himself  not  clear  that  the 
bone  had  gone  into  his  trachea,  or  whether  his  cough  was  not 
attributable  to  a  chill  caught  on  the  cold  night  of  his  attack  whilst 
waiting  at  the  doctor's  door. 

He  went  out  soon  after  this  to  his  practice  in  the  South  of  France, 
but  the  cough  continued,  and  within  six  or  eight  weeks  of  his  first 
seizure  the  expectoration  had  become  copious,  purulent,  and  offen- 
sive. He  passed  through  the  winter,  however,  fairly  well,  and  had 
not  lost  materiall}'  in  flesh  or  strength  by  the  autumn  of  1902. 
Dr.  Ilott  had  seen  him  in  August,  and  his  chief  complaint  then  and 
afterwards  was  of  purulent  and  very  foetid  expectoration,  which 
came  on,  and,  as  he  expressed  it,  "  welled  up  "  into  his  mouth  when- 
ever he  stooped,  as,  for  instance,  in  lacing  his  boots.  The  chest  was 
everywhere  resonant,  and  on  auscultation  no  morbid  signs  were 
detected,  except  deficient  respiratory  murmur  over  the  lower  part  of 
the  right  lung.  The  note  of  him  on  November  4,  1902,  was  that  there 
was  a  small  area  of  dulness  in  the  right  interscapular  region,  involv- 
ing the  base  of  the  scapula  opposite  the  spinous  process ;  that  the 
respiratory  murmur  here  was  weak  and  semi-bronchial,  with  a  few 
fine  rales ;  and  that  over  the  right  lung  below  the  sounds  were  deficient 
and  attended  with  slight  inconstant  wheeze. 

The  probability  of  there  being  a  piece  of  bone  impacted  in  the 
bronchus  was  fully  recognised,  there  being  still  a  doubt,  however, 
whether  it  might  not  have  made  an  abscess  diverticulum  from  the 
oesophagus.  The  patient's  own  sense  of  an  obscure  discomfort  led 
him  more  than  once  to  express  a  doubt  whether  the  bone  might  not 
h.ave  lodged  in  some  point  of  his  oesophageal  tract.  Dr.  Ilott  sent  him 
to  Dr.  Walsham,  who  took  two  skiagrams,  and  recognised  a  shadow 
on  the  right  side  of  the  cardiac  shadow.  Dr.  Walsham  was  kind 
enough  to  send  the  prints,  which  were  excellent,  but  did  not,  in  our 
opinion,  satisfactorily  locate  any  foreign  body.  The  late  Sir  James 
Mackenzie  Davidson  also  was  so  good  as  to  devote  much  time  and 
care  to  the  case,  with  an  equally  negative  result. 

Mr.  S.  continued  at  his  work,  and  did  not  complain  of  any  paroxysms 
of  cough  or  dyspnoea,  but  only  of  the  annoyance  of  the  expectoration 
and  fcetor  of  breath.  The  expectoration  was  examined  on  several 
occasions  in  the  autumn  of  1902.  It  consisted  of  almost  pure, 
thin,  difBuent  pus,  foul-smelling,  and  containing  very  little  mucus. 
Numerous  micrococci  were  present,  but  no  tubercle  bacilli  nor  elastic 
tissue   elements.     At    this    time   he    was    seen    in    consultation    with 


PLATE  XIII 


Foreign  Body  in  Beoxchus. 


To  face  p.  231. 


FOREIGN  BODY  (J'lECE  OF  BONE)  IN  BRONCHUS, 
LEADING  TO  CYLINDRICAL  BRONCHIECTASIS, 
SEPTIC  BRONCHO-PNEUMONIA,  AND  DEATH 
FROM  PNEUMOTHORAX 

At  A  a  piece  of  bone  is  seen  embedded  in  the  main  bronchus 
to  the  lower  lobe  of  the  right  lung.  Below  this  the  bronchi  are 
dilated  in  a  cylindrical  manner,  and  at  B  the  dilatation  expands 
into  a  cavity  the  size  of  a  walnut.  Adjoining  this,  septic  broncho- 
pneumonia had  occurred,  leading  to  pneumothorax,  and  a 
glass  rod  is  seen  passing  from  the  dilated  bronchus  through  the 
softened  lung  and  through  a  perforation  in  the  pleura  the  size  of 
a  sixpence.  At  C  oth»r  smaller  bronchi  are  seen  dilated  and  cut 
across. 

From  a  gentleman,  Mr.  T.  S.,  aged  fifty-one,  whose  case  is 
described  in  the  text,  with  the  result  of  the  autopsy  (see  p.  229). 

{From  the  Brompton  Hospital  Museum,     -i  natural  size.) 


PLATE  XIII 


ON   FOREIGN   BODIES   iN   THE   AIR-PASSAGES  23 1 

Sir  Rickman  Godlee,  but  it  was  decided  that  no  surgical  interference 
could  be  recommended,  as  the  exact  locality  of  the  foreign  body,  if 
present,  could  not  be  demonstrated. 

He  went  out  to  the  South  again  after  Christmas,  and  returned 
with  more  evident  signs  of  advanced  disease  upon  him.  His  finger- 
ends  were  enlarged,  he  had  lost  flesh  considerably,  and  in  the  course 
of  the  summer  he  had  had  several  attacks  of  rather  severe  haemop- 
tysis. In  June,  1903,  his  temperature  was  raised,  his  breathing 
quicker,  and  the  expectoration  copious,  foetid,  and  frequently  blood- 
stained. There  was  impaired  resonance  at  the  right  base,  and  over 
an  area  in  the  mid-scapular  line  in  the  region  of  the  ninth  and  tenth 
ribs  the  respiration  was  distinctly  cavernous  at  times,  with  rales  of 
a  liquid  or  sucking  character.  Some  pleuritic  friction  was  also 
audible,  and  a  few  crepitations  were  heard  at  the  left  base.  The 
question  of  surgical  interference  was  again  considered  with  Sir 
Rickman  Godlee,  and  Sir  James  Mackenzie  Davidson  took  another 
skiagram.  On  this  occasion  a  distinct  square  shadow  could  be  seen 
corresponding  with  the  area  over  which  cavernous  breathing  was 
audible,  and  which  moved  up  and  down  with  deep  respiratory  move- 
ments, but  this  was  not  thought  to  be  due  to  the  presence  of  a  foreign 
body  in  that  position. 

About  July  30  he  had  a  severe  haemorrhage,  for  which  Dr.  Ilott 
treated  him,  and  on  its  subsidence,  at  the  request  of  Dr.  Ilott,  his 
admission  was  secured  into  the  Brompton  Hospital.  He  became 
rapidly  worse,  however,  and  on  August  10  was  seized  with  acute 
pain  in  the  side,  and  was  found  by  Dr.  Kidd  to  have  developed 
pneumothorax,  followed  by  rapid  effusion.  Sixteen  ounces  of  thin, 
purulent  fluid  and  some  air  were  drawn  off  to  relieve  distress.  He 
died  on  August  14. 

Post-mortem  Examination  by  Dr.  H-S.  Hartley. — The  right  lung 
was  collapsed,  except  for  adhesions  at  the  apex  and  in  the  region  of 
the  diaphragm.  The  pleural  cavity  contained  air  and  about  one  pint 
of  thin  pus.  An  opening  in  the  pleura,  the  size  of  a  sixpenny-piece, 
was  found  near  the  base  of  the  lower  lobe  in  the  posterior  axillary 
line  (Plate  XIII).  The  patch  of  lung  here  presenting  was  softened, 
and  in  it  a  hole  was  found,  which  admitted  a  large  probe,  and  which 
communicated  with  the  main  bronchus  to  the  lower  lobe.  In  this 
bronchus,  about  an  inch  from  its  commencement,  a  triangular  piece 
of  bone,  |  by  f  inch,  was  found ;  it  lay  in  an  ulcerated  patch,  and 
could  be  removed  with  ease.  The  bronchi  below  were  cylindrically 
dilated  and  much  congested,  with  foul-smelling  contents,  the  chief 
bronchus  expanding  near  its  extremity  into  a  cavity  of  about  the  size 
of  a  walnut,  which  corresponded  in  situation  to  the  point  over  which 
cavernous  respiration  was  heard  during  life.  From  the  lower  end  of 
this  cavity  there  extended  a  sinus  downwards  and  outwards  to  an  area 
of  broncho-pneumonic  softening  at  the  surface  of  the  lung,  where  the 
perforation  had  occurred.  The  lung  tissue  of  the  right  lower  lobe 
had  undergone  fibrosis.     The  bronchi  in  the  upper  and  middle  lobes 


232  DISEASES    OF   THE   LUNGS   AND   PLEURA 

above  the  piece  of  bone  were  distinctly  dilated,  but  less  so  than  in  the 
lower  lobe. 

In  the  left  lung  the  bronchi  to  the  lower  lobe  were  dilated  and  in- 
flamed, and  those  in  the  upper  lobe  were  a  little  larger  than  natural. 
This  (left)  lung  showed  but  little  fibrosis,  but  presented  patches  of 
septic  broncho-pneumonia. 

This  case,  when  we  look  back  upon  it  from  the  end  to  the 
beginning,  illustrates  most  of  the  features  characteristic  of 
the  presence  of  a  foreign  body  in  the  bronchus,  and  in  the 
course  of  comments  upon  each  set  of  symptoms  as  they 
presented  themselves  we  shall  be  enabled  to  bring  before  the 
reader  the  main  features  of  the  disease. 

We  have  (i)  a  definite  choking  attack.  (2)  A  lull  into  com- 
parative comfort,  with  a  vague  sense  of  general  uneasiness  or 
irritation.  (3)  A  cough  then  comes  on,  which  may  or  may 
not — but  in  this  case  did  not,  at  all  events,  in  the  earlier 
periods — present  special  features.  (4)  The  expectoration 
becomes  more  copious  and  offensive.  (5)  The  physical  signs, 
at  first  very  obscure,  gradually  assume  the  characters  of 
chronic  basic  one-sided  bronchiectasis,  with  fibrosis  of  the 
lung.  (6)  Haemoptysis  occurs  towards  the  end  of  the  illness. 
(7)  Some  acute  incidents,  usually  of  septic  origin,  such  as 
broncho-pneumonia,  abscess,  empyema,  in  this  case  pneumo- 
thorax, bring  the  sufferings  of  the  patient  to  an  end.  (8)  The 
X-rays  may  or  may  not,  according  to  its  structure,  reveal  the 
presence  of  the  foreign  body.     In  this  case  they  did  not  do  so. 

A  stormy  onset,  an  acute  choking  fit,  is  the  rule  in  cases  of 
foreign  bodies  entering  the  trachea,  but  the  intensity  of  the 
attack  varies  much  with  the  character  of  the  body  inhaled  and 
the  state  of  the  patient.  It  is  obvious  that  a  rough,  angular 
and  hard  substance  will  excite  much  more  irritation  than  one 
which  is  smooth,  rounded,  or  soft.  In  some  cases  the  body 
is  inhaled  when  the  patient  is  asleep,  or  under  an  anaesthetic, 
or  in  a  fit,  and  in  this  way  may  excite  no  preliminary  spasm. 
Thus,  a  molar  tooth  was  found  post-mortem  by  our  colleague 
Dr.  Young  in  the  bronchus  of  a  patient  who  had  died  with 
uraemic  convulsions  in  the  Middlesex  Hospital.  It  had  prob- 
ably become  dislodged  in  the  nurse's  endeavour  to  prevent 
the  clenching  of  the  jaws  in  the  convulsions  during  which  the 
patient  died;  it  had  caused  no  symptoms,  and  had  evidently 
only  been  in  the  bronchus  a  short  time  before  death.     A  piece 


ON   FOREIGN   BODIES   IN  THE   AIR-PASSAGES  233 

of  tooth-filling  or  an  extracted  tooth  may  similarly  be  inhaled 
into  the  bronchus  during  a  dental  operation  under  an 
anaesthetic. 

A  few  years  ago  one  of  us  was  consulted  in  the  case  of  a 
gentleman  with  severe  incessant  and  paroxysmal  cough, 
attended  with  the  expectoration  of  a  glairy,  blood-stained 
mucus.  He  had  been  riding  in  the  Park,  and  was  supposed 
to  have  had  a  fit,  causing  him  to  fall  off  his  horse.  He  was 
carried  home  insensible,  and  on  return  of  consciousness  pre- 
sented the  symptoms  described.  There  were  crepitations, 
which  were  regarded  as  due  to  blood  within  the  tubes  at  the 
left  subclavicular  region,  with  very  feeble  breath-sound.  The 
case  had  not  the  characters  of  tuberculous  disease,  but  no 
history  of  foreign  body  could  at  the  time  be  elicited,  although 
carefully  inquired  for.  He  was  not  seen  again  by  us  after  the 
first  few  days  of  his  illness  until  some  three  months  later, 
when,  having  suffered  meanwhile  from  a  severe  cough  and 
increasingly  purulent  expectoration,  he  had  expelled  with  a 
severe  paroxysm  a  pipe  mouthpiece  about  f  inch  long.  He 
now  recalled  to  mind  that  he  was  smoking  a  pipe  at  the  time 
of  his  accident ! 

The  practical  point,  then,  in  all  cases  is  never  to  pass  over 
without  most  careful  scrutiny  any  history  of  attack  suggestive 
of  the  inhalation  of  a  foreign  body,  or  any  occurrence  pre- 
ceding the  development  of  symptoms  that  may  suggest  the 
possibility  of  such  reception. 

The  lull  of  symptoms  that  often  follows  the  initial  dyspnoea 
for  some  days,  and  even  some  weeks,  and  which  is  due  to  the 
penetration  of  the  foreign  body  beyond  the  sensitive  terri- 
tory of  the  glottis  into  the  comparatively  insensitive  bronchus, 
tends  to  put  the  doctor  and  the  patient  off  guard  as  to  the  true 
nature  of  the  cause.  In  the  case  of  Mr.  S.,  he  himself  and 
some  who  saw  him  in  the  earlier  stages  were,  for  this  reason, 
sceptical  as  to  the  foreig'n  body  having  entered  his  larynx, 
and  were  inclined  to  attribute  his  coug'h  to  a  bronchial  cold 
caught  from  exposure  on  that  November  night.  A  diagnosis, 
therefore,  of  the  presence  of  a  foreign  body  having  been 
made,  it  is  not  to  be  put  aside  by,  nor  is  safety  to  be  augured 
from,  a  temporary  absence  of  further  symptoms.  Many 
authors  since  the  time  of  Louis  have  borne  witness  to  the 
intervening  periods  of  calm  that  often  occur  between  the  first 


234  DISEASES   OF   THE  LUNGS   AND   PLEURA 

attack  and  the  occurrence  of  secondary  symptoms.  Dr.  Hoff- 
mann'** observes  :  "  In  many  cases,  after  an  initial  violent  fit 
of  coughing,  weeks  and  months  may  elapse  during  which  the 
patient's  comfort  is  not  disturbed." 

There  was  not  in  this  case  anything  distinctive  about  the 
cough,  but  in  many  others,  such  as  that  of  the  gentleman 
alluded  to  who  inhaled  the  pipe  mouthpiece,  the  cough  is  very 
paroxysmal,  and  has  even  been  mistaken  for  whooping- 
cough.^  Sometimes,  as  in  the  case  of  a  child  recorded  by 
Mr.  Kellock,^  the  patient,  after  the  first  severe  paroxysm,  will 
have  intervals  of  comfort  for  some  hours,  but  will  wake  up  in 
the  night,  or  be  seized  after  crying  with  intense  dyspnoea  and 
lividity.  It  is  evident  that  in  these  cases  the  foreign  body 
becomes  projected  from  its  nidus  in  the  relatively  insensitive 
bronchus  towards  the  larynx,  which  is  supplied  by  the  sensi- 
tive superior  laryngeal  nerves. 

As  the  case  goes  on,  if  the  foreign  body  remains,  the  cough 
continues,  and  is  accompanied  by  expectoration,  at  first 
mucous,  but  soon  becoming  purulent,  and  then  foetid,  and 
more  and  more  copious  in  amount.  A  symptom  which  was 
so  pronounced  in  the  case  which  we  have  described,  namely, 
the  welling  up  into  the  throat  of  foetid  purulent  matter  on 
stooping,  is  a  more  or  less  prominent  feature  of  bron- 
chiectasis, and  we  presume  that  it  was  due  in  this  case  to  the 
positional  displacement  of  the  foreign  body  permitting  the 
more  or  less  pent-up  secretion  from  below  to  pass. 

Haemoptysis  is  sometimes  an  early  symptom.  More  fre- 
quently it  occurs  in  the  later  stage,  and  it  is  naturally  most 
common  in  those  cases  in  which  hard,  irregular  bodies  have 
been  inhaled. 

The  physical  signs  are  as  a  rule  slight  to  the  point  of 
obscurity.  Should  the  body  be  movable  in  the  trachea,  the 
bruit  de  grelottement,  already  described,  may  be  audible,  but 
otherwise  feebleness  of  breath-sound  over  one  lung  below 
the  seat  of  the  obstruction  is  the  only  constant  early  sign. 
There  may  soon  be  developed,  as  in  the  case  of  Mr.  S.,  at 
and  about  the  point  of  obstruction,  an  area  of  impaired  per- 
cussion note,  with  fine  rales,  due  to  hyperaemia  in  the  neigh- 
bourhood of  the  offending  body.  Some  variable  sibilant  or 
mucous  sounds  are  scattered  over  the  affected  side.  If  the 
obstruction  be  at  all  complete,  the  movement  on  that  side  will 


ON   FOREIGN   BODIES    IN   THE   AIR-PASSAGES  235 

be  obviously  lessened.  Later  some  dulness  will  be  found  at 
the  base  of  the  lung;  perhaps  some  friction  may  be  heard,  or 
the  signs  of  effusion  may  gather  there.  As  a  rule,  as  the 
illness  proceeds,  the  signs  become  those  of  a  gradual  con- 
densation of  the  lung,  varying  from  time  to  time  from  mere 
silence  to  patchy  bronchial  or  even  cavernous  breath-sound 
and  localised  pectoriloquy,  always,  however,  on  the  scale  of 
weakened  breath-sound,  and  indicative  of  a  fibrotic  and  bron- 
chiectatic  lung.  An  empyema  may  form,  or  an  abscess  may 
develope  in  the  lung,  or  a  fistula  may  extend  from  the 
obstructed  bronchus  through  the  chest  wall,  causing  a  thor- 
acic abscess  or  a  purulent  pneumothorax,  as  happened  in  the 
above  related  case.  At  first  the  signs  are  always  one-sided; 
later  on,  towards  the  end,  septic  incidents  occur  in  the  other 
lung  or  in  distant  parts,  cerebral  abscess  being  not  infre- 
quently observed. 

Diagnosis. — The  diagnosis  rests  upon  an  accurate  history 
of  seizure,  followed  by  the  symptoms  and  signs  of  an  incom- 
plete obstruction  to  the  function  of  one  lung,  with  bronchial 
irritation,  and  subsequently  bronchiectasis  and  fibrosis. 

It  will  often  happen  that  the  patient  is  only  brought  to  us 
in  the  later  stage  of  fibrosis  and  bronchiectasis,  and  then  the. 
difficulties  may  be  great  in  distinguishing  the  case  from  one 
of  abscess  of  the  lung,  empyema,  or  phthisis.  An  examination 
into  all  its  features  will,  however,  usually  lead  us  to  recog- 
nise that  we  have  to  deal  with  a  one-sided  bronchiectasis,  and 
we  must  from  that  proceed  carefully  to  inquire  into  the  his- 
tory of  attack,  and  for  any  circumstances  that  may  point  to 
the  reception  of  a  foreign  body.  It  must  be  remembered  that 
a  large  proportion  of  cases  of  bronchiectasis  are  one-sided; 
but  when  a  one-sided  bronchiectasis  comes  on  apparently  as 
a  primary  disease,  and  cannot  be  explained  by  a  history  of  an 
antecedent  bronchitis,  pneumonia,  or  pleurisy,  the  possible 
presence  of  a  foreign  body  should  be  carefully  inquired  for. 
It  is,  again,  to  be  remembered  that  the  second  lung  becomes 
involved  in  the  later  stages  of  all  cases,  whatever  the  source 
of  the  bronchiectasis  may  be. 

An  examination  by  the  X-raiys  should  be  made,  but  in 
diagnosis  too  much  must  not  be  expected  from  this  source. 
When  the  foreign  body  is  metallic  or  of  pebbly  character,  as 
in  Class  I.  in  our  table,  in  some  cases  of  Class  II.,  and  perhaps 


236  DISEASES   OF  THE  LUNGS   AND   PLEURA 

in  Class  V.,  it  will  be  well  shown  up  and  located  in  a  skiagram. 
But  when  the  obstruction  is  of  cartilaginous  or  fleshy- 
material,  or  if,  being  of  bony  structure,  it  be  impacted  beneath 
the  shelter  of  the  scapula,  it  may  be  impossible  to  detect  it 
by  this  means.  Looking  back  upon  the  case  described,  due 
weight  was  perhaps  not  attached  to  the  difficulty  of  demon- 
strating the  bone  in  this  position. 

At  the  time  at  which  Mr.  S.  was  under  observation  the 
method  of  bronchoscopy  or  the  direct  examination  of  the 
interior  of  the  trachea  and  bronchi,  first  brought  into  practical 
use  by  Killian,  was  in  its  infancy.  It  is  now  famiUar  to  all 
physicians  interested  in  laryngological  and  chest  work,  and  it 
is  in  cases  like  the  present  that  it  is  of  especial  value.  Had 
it  been  available,  the  piece  of  bone  would,  in  all  probability, 
have  been  detected,  and,  judging  from  the  loose  manner  in 
which  it  lay  in  the  bronchus  at  the  autopsy,  its  removal  by  a 
little  careful  manipulation  would  have  been  possible.  The 
method  should  be  employed  in  all  cases  in  which  doubt 
remains  as  to  the  presence  of  a  foreign  body.  Its  value  in 
treatment  we  shall  consider  later. 

Prognosis. — The  reception  of  a  foreign  body  into  the  air- 
passages  is  a  serious  occurrence,  the  gravity  of  which  varies 
with  the  nature  of  the  material  inhaled.  Excluding  from  our 
reckoning  such  trivial  matters  as  small  breadcrumbs,  flies, 
etc.,  that  may  pass  into  the  trachea  and  occasion  only  tem- 
porary inconvenience,  a  glance  at  the  table  on  p.  226  shows 
that  the  total  mortality  among  128  cases  not  operated  upon 
was  37-5  per  cent.,  reduced  to  31-4  per  cent,  if  we  include 
those  treated  by  operation,  and  that  this  mortality  corre- 
sponds closely  with  that  of  the  106  cases  in  Class  II.  of  hard, 
irregular  bodies.  This  latter  class  includes  the  greatest 
number,  and  is,  therefore,  perhaps  the  most  trustworthy  for 
percentages.  The  bodies  included  in  it  (teeth,  bones,  pipe- 
stems,  needles,  peg-top  points,  etc.)  are  highly  irritating,  and 
often  directly  septic.  In  Classes  IV.  and  V.  the  foreign  bodies 
are  of  a  kind  likely  to  become,  either  by  their  primary  form 
(plum-stones,  etc.)  or  their  secondary  swelling  when  soaked 
(wheat,  maize,  beans,  etc.),  more  tightly  jammed  into  the 
bronchial  calibre.  The  least  harmful  bodies  seem  to  be  the 
smooth  impermeable  bodies,  such  as  coins,  bullets,  buttons, 
beads,  etc.,  giving  a  mortality  of  15  per  cent.;  but  the  number 


ON   FOREIGN   BODIES    IN   THE   AIR-PASSAGES  237 

of  these  cases  is  comparatively  small  from  which  to  draw 
percentage  conclusions. 

In  regard  to  the  influence  of  the  older  methods  of  operative 
treatment  upon  the  mortality,  we  may  note  that  of  82  cases 
in  which  operative  treatment — mostly  tracheotomy — was 
adopted,  22  per  cent,  died;  whereas,  of  128  cases  in  which  no 
operation  was  attempted,  37-5  per  cent.  died. 

Treatment. — Two  principles  are  laid  down  by  Sir  F.  Semon 
and  Dr.  Watson  Williams^  in  their  article  upon  the  presence 
of  foreign  bodies  in  the  air  and  upper  food  passages :  first, 
no  foreign  body  the  presence  of  which  has  actually  been 
detected  should  be  permitted  to  remain  impacted,  without 
an  attempt  to  remove  it  by  every  justifiable  means,  even 
although  at  the  time  it  may  not  produce  active  symptoms; 
secondly,  no  attempt  should  ever  be  made  forcibly  to  ram 
down  an  angular  or  pointed  foreign  body.  It  is  unnecessary 
after  what  has  already  been  said  to  dwell  upon  these  rules 
of  practice.  When  the  foreign  body  has  penetrated  to  the 
bronchi,  the  first  dictum  still  holds  good. 

These  being  the  fundamental  ideals  with  regard  to  treat- 
ment, we  may  describe  the  main  methods  of  procedure  as 
follows : 

If  the  first  paroxysm  has  passed,  and  the  services  of  an 
operator  skilled  in  bronchoscopy  are  available,  a  search  should 
be  made  without  delay  by  this  method  for  the  foreign  body, 
and  its  removal  attempted.  With  the  recently  improved 
manipulative  methods  and  instruments  designed  by  Killian, 
Briinings,  Von  Schrotter,  and  others,  the  facilities  for  extrac- 
tion have  been  greatly  increased,  and  the  attempt  is  now 
successful  in  the  majority  of  cases.  The  pipe-stem  referred 
to  in  the  above-quoted  case,  although  ultimately  expelled  by 
Nature's  efforts,  might  readily  have  been  detected  by  bron- 
choscopy, and  would  probably  have  been  easily  removed  by 
this  means. 

Whether  superior  or  inferior  bronchoscopy  should  be  per- 
formed— the  former  being  the  introduction  of  the  tube 
through  the  mouth  and  glottis,  and  thus  into  the  trachea  and 
bronchi;  the  latter  its  introduction  through  a  previously  per- 
formed tracheotomy  wound — must  depend  upon  various  con- 
siderations, the  most  important  of  which  are  the  size  and 
character  of  the  foreign  body,  but  we  may  add  that  in  the 


238  DISEASES    OF   THE  LUNGS   AND   PLEURA 

majority  of  cases  superior  (or  per-oral)  bronchoscopy  will 
prove  successful. 

Professor  von  Eicken/  of  Freiburg,  reported  in  1909  upon 
303  patients  of  all  ages  (195  children  under  fifteen  and  108 
adults)  treated  by  superior  or  inferior  bronchoscopy.  Of  this 
number,  in  233,  or  76-9  per  cent.,  the  foreign  body  was  located 
and  extracted,  and  recovery  ensued.  In  36  (ii"9  per  cent.) 
the  result  was  only  partially  successful,  the  lung  being  in 
many  cases  already  so  diseased  that,  in  spite  of  the  successful 
removal  of  the  foreign  body,  death  could  not  be  averted,  and 
at  most  only  partial  improvement  followed.  In  34  (ii"2  per 
cent.)  the  operation  was  unsuccessful,  the  foreign  body  in 
several  cases  not  being  found,  or  its  removal  proving  imprac- 
ticable. Included  in  this  group  are  also  four  patients  who 
succumbed  to  cocaine-poisoning,  and  one  who  died  under 
chloroform.  Two  children  also  died  of  suffocation  from  the 
fracture  of  the  foreign  body  (a  softened  bean)  during  an 
attempt  at  its  removal  by  superior  bronchoscopy,  and  the 
consequent  inhalation  of  the  fragments. 

Since  1909  the  results  of  this  method  of  treatment  have 
improved  with  advancing  experience,  and  at  the  17th  Inter- 
national Congress  of  Medicine  held  in  London  in  1913, 
Dr.  Chevaher  Jackson,^  who  introduced  the  discussion  on 
this  subject,  reported  that  in  the  last  182  consecutive  cases  of 
bronchoscopy  for  foreign  bodies  which  he  had  had  under  his 
care,  in  177  the  foreign  body  was  successfully  removed.  In  3 
only  had  the  patient  died — a  mortality  of  vj  per  cent.  Dr. 
Jackson  uses  only  per-oral  bronchoscopy,  being  unconvinced 
of  the  advantages  attributed  to  tracheotomic  bronchoscopy, 
while  the  disadvantages  are  many  and  obvious. 

Without  pressing  the  actual  figures  too  far,  we  may  note 
that  these  results  contrast  most  favourably  with  those 
obtained  by  older  methods  of  treatment,  as  recorded  by  the 
late  Mr.  Durham,'"  Weist,"  Preobraschensky,"  and  others, 
and  as  indicated  on  our  table  on  p.  226,  and  there  can  be  no 
question  that  direct  examination  and  extraction  is  the  right 
procedure  to  adopt,  provided  the  surrounding  circumstances 
permit.  When,  however,  the  requisite  instruments  and  skill 
are  not  available,  and  if  the  first  paroxysm  has  passed,  and  if 
we  know  also  that  the  foreign  body  is  of  the  smooth,  hard 
variety,  referred  to  in  Class  I.  of  our  table,  simple  inversion, 


ON  FOREIGN   BODIES    IN   THE   AIR-PASSAGES  239 

or  inversion  with  tracheotomy,  may  be  tried.  Under  this 
treatment  the  patient  is  inverted  v^^ith  slapping  or  thumping 
shocks  between  the  shoulders.  This  should  only  be  done  with 
instruments  ready  at  hand  for  tracheotomy  should  the 
paroxysm  of  dyspnoea  consequent  on  displacement  of  the 
body  to  the  glottis  be  too  severe. 

In  a  considerable  number  of  cases  the  foreign  body  has 
been  thus  expelled.  A  famous  instance  of  the  kind,  in  which, 
however,  tracheotomy  was  performed,  is  that  recorded  by 
Sir  Benjamin  Brodie"  of  the  celebrated  engineer  Brunei,  who, 
whilst  playing  with  some  children,  inhaled  a  half-sovereign 
into  his  bronchus.  On  the  sixteenth  day,  the  patient  having 
been  placed  prone,  with  his  head  and  shoulders  slanting  down- 
wards, "he  immediately  had  a  distinct  perception  of  a  loose 
body  slipping  forward  along  the  trachea.  A  violent,  con- 
vulsive cough  ensued.  On  resuming  the  erect  position,  he 
again  had  the  sensation  of  a  loose  body  moving  in  the 
trachea  .  .  .  towards  the  chest."  Two  days  later,  in  presence 
of  Dr.  Chambers  and  some  other  colleagues,  the  experiment 
was  repeated  by  means  of  an  inclined,  hinged  platform.  On 
striking  the  back  with  the  hand  over  the  right  bronchus,  with 
the  head  lowered  to  an  angle  of  80  degrees  with  the  floor, 
violent  cough  was  set  up  without  result,  and  the  experiment 
was  twice  repeated,  on  the  third  time  causing  such  an  alarm- 
ing degree  of  choking  that  it  was  not  further  proceeded  with. 
A  week  later  tracheotomy  was  performed,  and  forceps  intro- 
duced in  an  attempt  to  seize  the  coin,  but  without  result.  The 
tracheotomy  wound  was  kept  open,  and  after  a  further  delay 
of  ten  days  the  patient  was  again  inverted,  and  after  two  or 
three  strokes  on  the  back  the  coin  was  expelled  through  the 
mouth.  "No  spasm  took  place  in  the  muscles  of  the  glottis, 
nor  was  there  any  of  that  inconvenience  and  distress  which 
had  caused  no  small  degree  of  alarm  on  the  former  occasion." 

In  cases  of  angular  bones,  pointed  instruments,  and  bodies 
of  hke  nature,  if  more  modern  methods  of  treatment  be  not 
available,  tracheotomy  should  be  performed,  and  an  attempt 
made  to  extract  the  body  by  means  of  slender  forceps,  or, 
perhaps,  a  loop  of  silver  wire.  Pneumotomy,^''  or  the  cutting- 
down  through  the  chest  wall  directly  upon  the  foreign  body, 
is  an  operation  which,  though  by  no  means  so  hazardous  as 
formerly,  is  yet  not  free  from  risk,  and  should  be  reserved  for 


240  DISEASES    OF   THE   LUNGS   AND   PLEUR^: 

those  rare  cases  in  which  other  methods  have  failed.  We 
have,  on  page  164,  related  a  successful  case  bearing  upon  this 
subject. 

REFERENCES. 

^  Harold,  or  the  Last  of  the  Saxon  Kittgs,  by  Bulwer  Lytton ;  see  also 
The  History  of  the  Norman  Conquest  of  England,  by  Edward  A.  Freeman, 
M.A.,  1868,  Note  W  to  p.  351,  vol.  ii.,  and  Appendix,  p.  6io. 
Freeman's  account  renders  it  clear  that  Earl  Godwin  died  of  cerebral 
hffimorrhage. 

^  {a)    "  Corps    Strangers    du    Larynx    et    des    Voies    Aeriennes,"    par 
F.    Guyon,    Dictionnaire    Encyclofedique    des    Sciences    Midicales, 
pp.  698  and  725,  deuxieme  serie,  tome  i.,  1872. 
(b)  Guyon,  loc.  cit.,  p.  713. 

^  A  Treatise  on  the  Diagnosis  and  Treat7nent  of  Diseases  of  the  Chest,  by 
WiUiam  Stokes,  M.D.,  1837,  New  Sydenham  Society  edition,  part  i.,  p.  234. 
London,  1882. 

*  [a]   "  Diseases  of  the  Bronchi,  Lungs,   and  Pleura,"  by  Friedrich  A. 

Hoffmann,  M.D.,  of  Leipzig,  Nothnagel's  Encyclofedia  of  Practical 
Medicine,    English    edition,    edited,    with    additions,    by    John    H. 
Musser,  M.D.,  p.  37.     Philadelphia  and  London,   1903. 
{b)  Loc.  cit.,  p.  70. 

*  "  On  the  Effects  produced  by  the  Retention  of  Foreign  Bodies  for 
Lengthened  Periods  in  the  Bronchial  Tubes,"  by  Rickman  John  Godlee, 
M.S.,  F.R.C.S.,  Transactions  of  the  Royal  Medical  and  Chirurgical 
Society,  i8g6,  vol.  Ixxix.,  p.  201,  Case  3. 

'  "  A  Case  of  Foreign  Body  (Haricot  Bean)  impacted  in  the  Left 
Bronchus  :  removal  by  Operation,"  by  Thomas  H.  Kellock,  F.R.C.S.,  The 
I^ancet,  1902,  vol.   ii.,  p.   1322. 

^  "  On  Foreign  Bodies  in  the  Air  and  Upper  Food  Passages,"  by  Sir 
Felix  Semon,  K.C.V.O.,  M.D.,  F.R.C.P.,  and  P.  Watson  WiUiams,  M.D., 
Allbutt  and  Rolleston's  System  of  Medici7ie,  vol.  iv.,  part  ii.,  p.  326. 
London,  1908. 

*  "  Die  direkte  Laryngo-Tracheo-Bronchoskopie,"  von  Carl  von  Eicken 
(Freiburg  i.  Br.),  Die  Deutsche  Klinik,  1909. 

See  also  "  Direct  Methods  of  Examining  the  Air  and  Food  Passages," 
by  Carl  von  Eicken,  M.D.,  British  Medical  Journal,  1910,  vol.  ii.,  p.  1613. 

'  "  Recent  Progress  of  Endoscopic  Methods  as   applied  to  the  Larynx, 
Trachea,  Bronchi,  CEsophagus  and  Stomach,"  by  ChevaUer  Jackson,  M.D., 
Transactions   of   the    lyth   International    Congress    of   Medicine,    London, 
■1913,  Sections  15  and  16,  p.  i. 

"  "  Foreign  Bodies  in  the  Air-Passages,"  by  Arthur  E.  Durham,  Esq., 
A  System  of  Surgery,  edited  by  T.  Holmes,  M.A.,  and  J.  W.  Hulke,  F.R.S., 
third  edition,  vol.  i.,  p.  765.     London,  1883. 

"  "  Foreign  Bodies  in  the  Air-Passages,"  by  J.  R.  Weist,  M.D.,  of 
Richmond,  Indiana,  Transactions  of  the  American  Surgical  Association, 
Philadelphia,   1883,  vol.  i.,  p.   117. 


ON   FOREIGN   BODIES    IN   THE   AIR-PASSAGES  241 

*^  "  Uober  Fremdkorper  in  den  Athmungswegen,"  von  Dr.  S.  S.  Preobra- 
schensky  in  Moskau,  Wiener  Klinik,  1893,  Nos.  8-10. 

"  "  An  Account  of  a  Case  in  which  a  Foreign  Body  was  lodged  in  the 
Right  Bronchus,"  by  Sir  Benjamin  C.  Brodie,  Bart.,  F.R.S.,  Transactions 
of  the  Royal  Medical  and  Chirurgical  Society,  June,  1843,  vol.  viii.,  p.  286. 

"  {a)    "A   Case   of   Pneumotomy  for    Foreign   Body,"    by   Thomas   H. 
Kellock,    M.C.,    Proceedings    of    the    Royal    Society    of    Medicine 
[Clinical  Section),  vol.  vi.,  p.  64.     1913. 
(b)  "Pneumotomy   for    Foreign   Body,"    by    Noel   Braham,    F.R.C.S. 
(Edin.),  British  Medical  Journal,  1914,  vol.  i.,  p.   1123. 


16 


CHAPTER  XV 

ASTHMA 

On  more  closesy  regardng  the  several  varieties  into  which 
asthma  is  divisible  for  clinical  convenience,  it  will  be  observed 
that  they  represent  merely  aetiological  subdivisions  of  a 
disease  which  consists  essentially  of  a  paroxysmal  dyspnoea 
from  disturbed  innervation  of  the  bronchi,  leading  to  spas- 
modic contraction  of  these  tubes. 

Pathology. — The  theory  that  asthma  is  thus  the  result  of 
bronchial  spasm,  though  held  by  many  authorities  from 
Laennec  onwards,  has  not  been  universally  accepted,  some 
believing  that  the  disease  is  due  to  a  sudden  swelHng  of  the 
bronchial  mucous  membrane  from  turgescence  of  its  blood- 
vessels; others  that  it  results  from  a  special  form  of  inflamma- 
tion, a  "  bronchiolitis  exudativa  "  (Curschmann),  affecting  the 
smallest  tubes.  For  a  consideration  of  the  numerous  other 
theories  which  have  been  held  from  time  to  time  concerning 
the  true  nature  of  the  disease,  we  must  refer  the  reader  to 
Salter's'"  standard  work,  in  which  these  theories  are  well 
related. 

That  true  spasmodic  asthma  is  a  malady  in  which  the 
nervous  system  is  closely  concerned  is  supported  by  the 
following  cHnical  considerations  : 

1.  An  attack  of  asthma  may  supervene  in  the  course  of  a 
few  minutes,  or  even  seconds,  in  a  person  in  whom  there  can 
be  found  no  evidence  of  chest  disease. 

2.  Of  the  organic  lesions  which  can  be  said  in  different 
cases  of  asthma  to  have  led  up  to  the  spasmodic  seizures, 
there  are  none  which  singly  or  combined  are  proper  to  that 
disease.  Asthma,  it  is  true,  leads  on  to  certain  pathological 
conditions  recognisable  during  Hfe,  notably  emphysema,  chest 
deformity,  cardiac  disease,  and  visceral  congestions;  but  these 
lesions  are  distinct  mechanical  consequences  after  long  con- 
tinuance of  the  disease,  and  in  their  eadier  stages  are  totally 

242 


ASTHMA  243 

inadequate  to  account  for  the  asthmatic  phenomena.  We 
have  elsewhere  drawn  attention  to  the  intimate  analogy 
between  pure  asthma  and  vaso-motory  angina,  especially  in 
these  respects.* 

3.  The  family  histories  and  mental  proclivities  of  many 
asthma  patients,  the  capriciousness  and  intermittent  character 
of  their  attacks,  recall  to  mind  such  affections  as  neuralgia, 
migraine,  epilepsy,  and  emphasise  the  part  played  by  the 
nervous  system  in  the  pathology  of  the  disease. 

We  may  now  pass  to  a  consideration  of  the  question 
whether  a  spasm  of  the  muscular  tissue  of  the  bronchioles, 
the  contractility  of  which  was  originally  demonstrated  by  the 
late  Dr.  C.  J.  B.  Williams,^  is  the  cause  of  the  asthmatic 
attack.  The  arguments  in  support  of  this  theory  have 
received  very  cogent  and,  as  it  appears  to  us,  convincing  sup- 
port, from  the  work  of  Professors  Brodie  and  Dixon.* 

These  observers  have  shown,  by  means  of  an  ingenious 
method  of  recording  the  volume  of  air  entering  and  leaving 
the  lung  at  each  respiratory  act,  that  peripheral  stimulation 
of  the  vagus  leads  in  the  corresponding  lung  to  a  contraction 
of  the  muscular  walls  of  the  bronchi  and  a  constriction  of 
their  lumen,  resulting  in  a  great  diminution  of  the  volume  of 
air  inhaled.  With  this  change  an  over-distension  of  the  lung, 
as  in  asthma,  was  frequently  observed.  There  can  be  no 
doubt,  therefore,  that  under  the  influence  of  the  nervous 
system  marked  changes  of  calibre  in  the  bronchioles  can  be 
produced,  and  Dr.  Watson  Williams^  is  of  opinion  that  the 
asthmatic  paroxysm  is  due  to  an  exaggeration  of  the  con- 
traction stage  during  expiration  of  the  normal  respiratory 
rhythmic  movements  of  the  bronchi,  to  which  we  have 
referred  earlier  (see  p.  8). 

The  influence  of  drugs  was  next  investigated,  and  Drs. 
Brodie  and  Dixon  found  that  the  injection  of  muscarine  and 
pilocarpine  led  to  great  constriction  of  the  bronchioles  due 
to  peripheral  stimulation  of  the  vagal  nerve-endings,  and 
that  if  atropine,  hyoscyamine,  or  hyoscine  were  then  injected, 
dilatation  at  once  supervened  from  paralysis  of  the  same 
nerve-endings.  The  experiments  with  muscarine  were  espe- 
cially interesting,  for  the  animal  under  observation  suffered 

*  See  Table  comparing  Asthma  with  Angina  Pectoris  Vaso-motoria,  in 
Sir  Richard  Douglas  Powell's  article  on  "  Angina  Pectoris."-'' 


244  DISEASES    OF   THE  LUNGS   AND   PLEURA 

from  a  typical  asthmatic  paroxysm,  with  dyspnoea,  distended 
chest  and  scattered  sibilant  rales,  until  the  injection  of  atro- 
pine cut  short  the  attack.  The  experiments  with  chloroform 
and  ether  were  also  instructive,  the  results  showing  that  these 
drugs,  when  absorbed  through  the  bronchial  mucous  mem- 
brane, led  to  paralysis  of  the  nerve-endings,  thus  explaining 
their  good  effect  in  the  treatment  of  the  disease.  Of  great 
importance,  too,  was  the  observation  that  a  definite  reflex 
contraction  of  the  bronchioles  could  be  obtained  by  stimula- 
tion of  the  nasal  mucous  membrane. 

The  theory  of  bronchial  spasm  would  appear,  therefore, 
adequate  to  explain  the  asthmatic  attack.  Drs.  Brodie  and 
Dixon  draw  attention  also  to  certain  facts  which  militate 
against  the  theory  of  vascular  turgescence,  which  has  found 
in  the  past  not  a  few  supporters.  They  point  out,  in  the 
first  place,  that  it  is  illogical  to  assume  that  a  sudden  and 
marked  vascular  engorgement  may  be  expected  in  the 
bronchi,  simply  because  it  occurs  from  time  to  time  in  the 
nasal  mucous  membrane,  seeing  that  the  structure  of  the  two 
is  quite  dissimilar.  "The  nasal  mucous  membrane,"  they 
remind  us,  "especially  over  the  inferior  turbinate  bone  and 
lower  nasal  passages,  is  extremely  vascular,  and  in  many 
parts  large  venous  plexuses  are  found  encircled  by  bundles  of 
muscular  fibres,  thus  forming  a  sort  of  cavernous  erectile 
tissue  (Klein).  The  bronchial  mucous  membrane,  on  the 
other  hand,  is  thin,  and  possesses  what  is,  in  comparison,  a 
relatively  insignificant  blood-supply."  Again,  in  the  artificial 
asthma  produced  by  muscarine,  the  bronchi  were  not  found 
engorged,  nor  was  any  excessive  secretion  found  in  them. 
Further,  the  marked  turgescence  of  the  bronchial  mucous 
membrane,  produced  by  the  experiment  of  clamping  the  pul- 
monary vein,  never  gave  rise  to  diminution  of  air  entry  at  all 
comparable  to  that  seen  when  the  bronchioles  were  made  to 
contract. 

The  little  pellets  of  sputum  which  are  expectorated  towards 
the  end  of  an  attack  of  asthma  should  not  be  regarded  as  a 
sign  of  bronchitis,  but  are  to  be  attributed  rather  to  mechani- 
cal hyperaemia,  induced  by  disturbed  intrathoracic  pressure 
acting  for  a  considerable  time  upon  the  obstructed  tubes. 

etiology. — A  considerable  number  of  cases  of  asthma  are 
attributable  to  inherited  predisposition,  and  in  many  instances 


ASTHMA  245 

what  is  termed  a  "  neurotic  family  history  "  obtains,  although 
evidence  of  direct  inheritance  of  asthma  may  be  wanting. 
Epilepsy,  insanity,  neuralgia,  hysteria  and  asthma,  are  indeed 
diseases  all  within  the  range  of  interchangeability  in  famihes. 

Asthma  is  said  to  be  more  common  in  males  than  in 
females,  though  this  does  not  happen  to  be  in  accord  with 
our  own  experience,  and  it  is  stated  by  Dr.  SaUer  and 
others  to  occur  most  frequently  in  the  first  decade  of  hfe.  It 
is,  however,  often  first  manifested  between  puberty  and  early 
middle  life,  and  in  females  about  the  menopause.  Cases  com- 
mencing in  middle  or  later  Hfe,  and  they  are  not  very  infre- 
quent, have  in  our  experience  mostly  supervened  upon 
influenza,  others  from  the  gouty  plethora  induced  by  undue 
liberahty  in  diet,  and  a  few — one  notable  instance — from 
nervous  exhaustion  consequent  upon  the  cares  and  work  of 
official  life.  In  connection  with  the  setiology  of  asthma, 
especially  that  variety  commencing  in  early  life,  eczema  will 
occasionally  be  recorded;  in  later  hfe  sometimes  urticaria. 

Exciting  Causes  of  Asthma. — In  the  most  characteristic 
cases  of  asthma  the  exciting  causes  of  the  attack  are  opera- 
tive in  a  patient  with  an  idiosyncrasy,  often  hereditary,  which 
is  manifested  in  an  undue  sensitiveness  of  his  respiratory 
centres.  The  exciting  causes  are  of  central  or  reflex  origin, 
and  are  often  toxic  in  nature.  We  may  first  consider  toxic 
causes,  since  they  are  often  associated  with  the  others. 

It  has  recently  been  shown  by  Dr.  John  Freeman®  and  by 
Dr.  I.  Chandler  Walker'  of  Boston,  and  others,  that  in  many 
cases  the  asthmatic  attack  is  in  reality  of  anaphylactic  origin, 
the  patient  being  hypersensitive,  anaphylactic,  to  some  pro- 
tein, which  may  be  present  in  pollen,  animal  hairs,  food,  or 
bacteria,  and  which,  when  absorbed,  so  affects  him  as  to  pre- 
cipitate the  seizure. 

Dr.  Walker  examined  400  patients  suffering  from  asthma, 
and  found  that  191,  or  48  per  cent.,  gave  a  positive  skin  test, 
as  shown  by  a  marked  urticarial  wheal  produced  on  scarifying 
the  skin  through  a  solution  of  the  protein  in  question,  thus 
proving  the  patient  sensitive  to  the  variety  of  protein  tested. 

With  regard  to  the  class  of  protein  at  fault,  it  has  been  shown 
that  hypersensitiveness  to  a  food  protein,  whether  of  cereals 
(and  especially  wheat),  or  egg,  or  milk,  is  more  frequently 
to  be  observed  in  cases  commencing  in  infancy,  23  of  Dr, 


246  DISEASES   OF  THE  LUNGS   AND  PLEURA 

Walker's  34  cases  being  under  two  years  of  age.  In  later 
years,  when  caused  by  food  protein,  the  asthma  is  more  often 
attributable  to  other  articles  of  diet,  such  as  fish  or  potato. 

The  same  relationship  to  age  of  onset  is  true,  but  in  a  less 
degree,  in  regard  to  the  protein  present  in  hairs  (chiefly  those 
of  the  horse,  less  commonly  the  cat),  or  that  occurring  in 
feathers,  which  appears  to  be  responsible  for  a  good  many 
cases  of  asthma  commencing  before  the  age  of  ten,  and  less 
often  as  the  age  of  onset  advances.  Sensitisation  to  pollen 
protein,  producing  so-called  "hay  asthma,"  is  more  common 
in  cases  commencing  in  young  subjects,  but  is  by  no  means 
limited  to  such  patients;  while  bacterial  toxines,  notably  of 
staphylococcal  or  streptococcal  origin,  may  be  associated  with 
asthma  occurring  at  any  age. 

We  may  here  note,  as  probably  of  analogous  explanation, 
the  alarming  symptoms  of  dyspnoea,  failure  of  respiration,  and 
collapse,  which  have  sometimes  quickly  followed  the  subcu- 
taneous injection  of  serum,  whether  anti-diphtheritic  or  other, 
when  given  for  therapeutic  purposes  in  asthmatic  subjects, 
who  are  often  anaphylactic  to  horse  serum.  Of  28  such  cases 
collected  by  Dr.  Gillette,*  15  proved  fatal  (see  p.  264). 

Presumably  these  protein  bodies  act  directly  upon  the 
medullary  nerve  centres,  and  perhaps  asthmatic  phenomena 
sometimes  observed  in  renal  disease  from  retained  urinary 
products  may  be  similarly  caused.  We  have  already  alluded 
to  the  effect  of  muscarine. 

It  is  only  possible — so  far  as  present  technique  serves — in 
some  48  per  cent,  of  patients  to  trace  asthmatic  attacks  to 
such  proteid  sensitisation.  The  tests  in  the  remainder  of  Dr. 
Walker's  cases  proved  negative.  Other  cases  we  must  refer 
to  the  more  obvious  sources  of  reflex  irritation.  In  some 
cases  excitation  of  some  point  of  the  naso-pharyngeal  tract 
may  be  at  the  origin  of  the  trouble.  The  asthma  has  thus 
been  traced  to  the  presence  of  polypi,  adenoids,  or  sinus 
disease,  and  treatment  of  the  nasal  affection  has  led  to  a  dimi- 
nution in  the  number  of  attacks.  We  have  also  met  with  a 
few  well-marked  cases  in  which  the  asthma  paroxysm  has 
commenced  with  a  turgid  state  of  the  turbinate  membrane, 
causing  complete  occlusion  of  the  nares.  In  other  cases, 
again,  asthmatic  attacks  arise  from  more  direct  bronchial 
irritation,  as  in  bronchitis,  plastic  bronchitiSj  or  from  inhala- 


ASTHMA  247 

tion  of  inorganic  dust,  or  exposure  to  acrid  vapours,  or  to 
certain  atmospheric  influences  to  which  the  patient  may  be 
peculiarly  sensitive. 

Amongst  other  reflex  causes  are  gastro-intestinal  disturb- 
ances, especially  flatulent  distension  of  stomach  or  bowels, 
and  loaded  colon;  but  it  would  be  difficult  to  affirm  how  far 
the  influence  of  certain  proteins  may  not  also  be  concerned  in 
this  causation.  Less  common  sources  of  reflex  irritation  are 
connected  with  uterine  disturbances,  whether  menstrual  or 
climacteric,  and  those  derived  from  excitation  of  cutaneous 
nerves. 

Cutaneous  affections,  especially  of  the  eczematous  type,  are 
not  infrequent  precursors  of  asthma  in  young  children,  and 
the  late  Sir  Andrew  Clark  was  of  opinion  that  asthma  occa- 
sionally originated  in  an  urticarial  condition  of  the  air- 
passages. 

The  emotional  causes  which  may  be  responsible  for  the 
attack  no  doubt  act  in  a  reflex  manner,  impulses  originating  in 
the  cerebrum  stimulating  the  lower  centre  in  the  medulla. 
We  have  recorded  an  interesting  case  in  which  asthma,  vaso- 
motor angina,  and  menopausal  sweatings  have  shown  an 
interchangeability.-* 

Clinical  Varieties  of  Asthma. — In  accordance  with  the  vary- 
ing nature  of  the  exciting  cause,  diverse  clinical  varieties  of 
the  disease  have  been  described,  of  which  the  following  may 
be  mentioned : 

(i)  Idiopathic,  Essential,  or  True  Spasmodic  Asthma. — This 
has  been  held  to  include  those  cases  of  true  neurosis  in  which 
no  lesion,  whether  pulmonary  or  other,  can  be  found,  and  in 
which  the  exciting  cause  of  the  attack,  if  any  can  be  recog- 
nised, is  some  mental  or  emotional  disturbance,  for  example, 
mental  shock,  violent  emotion,  severe  anxiety;  or,  if  material, 
one  of  a  very  slight  and  ephemeral  kind,  such  as  a  brilliant 
light,  a  transient  odour,  the  momentary  application  of  cold  to 
the  surface,  and  the  like.  This  form  of  asthma,  as  already 
said,  can  be  best  compared  to  neuralgia,  epilepsy,  migraine, 
perhaps  also  mania.  The  neurosis  is  inherited  either  directly 
or  through  some  of  the  alHed  forms  mentioned.  The  attacks 
are  more  distinctly  periodic  than  in  any  of  the  other  forms  of 
asthma,  and  with  the  completion  of  each  attack  the  peculiar 
neurosis  often  seems  to  be  for  a  time  worn  out. 


248  I3ISEASES    OF   THE   LUNGS   AND    PLEUR.^ 

(2)  Catarrhal  or  Bronchitic  Asthma.  —  In  this  variety 
catarrhal  symptoms  precede  and  attend  those  characteristic 
of  asthma,  the  dyspnoeic  phenomena  being  due  to  direct 
irritation  of  the  bronchial  nerves,  or  more  probably,  as  we 
have  seen,  to  their  reflex  excitation.  Bronchitic  asthma  is 
but  a  catarrhal  affection  of  the  bronchial  tubes  in  a  subject 
predisposed  to  asthma;  the  special  character  of  the  disease 
being  derived  from  the  individual  peculiarity,  not  from  the 
catarrhal  affection  which  commonly  arises  in  the  ordinary 
way.  In  this  affection  during  the  acute  stage  the  spasm 
and  consequent  dyspnoea  are  more  or  less  continuous.  Sub- 
sequently, with  the  greater  freedom  of  secretion  and  expec- 
toration, the  dyspnoea  occurs  chiefly  in  the  early  morning 
after  a  few  hours'  sleep,  when  the  accumulation  of  mucus  in 
the  tubes  is  greatest,  and  with  its  expulsion  the  spasm  ceases. 

In  cases  of  old-standing  emphysema  fresh  bronchial  catarrh 
is  often  attended  with  dyspnoeal  seizures  of  an  asthmatic 
character  which  are  due  to  obstruction  of  the  tubes  by  mucus 
disturbing  the,  at  all  time?,  unstable  respiratory  equilibrium 
of  the  emphysematous  subject.  Only  in  popular  parlance 
can  such  cases  be  called  "asthma." 

(3)  Of  dust  asthma  we  shall  detail  a  well-marked  example 
arising  from  the  inhalation  of  wood  dust  (see  p.  264).  Other 
irritants  have  similar  effects  upon  a  certain  proportion  of 
those  exposed  to  them. 

(4)  Hay  asthma  is  a  variety  of  the  disease  which  is  often 
associated  with  that  intense  catarrh  of  the  conjunctivae  and 
of  the  nasal  mucous  membrane  which  is  termed  "hay  fever." 
The  researches  carried  out  at  Hamburg,  under  the  direction 
of  Professor  Dunbar,'  and  since  by  many  other  observers,  have 
greatly  extended  our  knowledge  of  the  aetiology  of  this  com- 
plaint, and  have  shown  that,  in  patients  whose  nervous 
system  is  sufficiently  receptive,  the  pollen  of  very  many 
grasses,  plants,  and  flowers  is  capable  of  producing  the 
attack.  Among  these  we  may  mention  rye,  oats,  barley, 
meadow-sweet,  golden  rod,  chrysanthemum,  and  aster.  In 
England  the  complaint  is  chiefly  produced  by  the  pollen  of 
hay  (Anthoxanthum  odoratum),  in  Germany  by  that  of  the 
flowering  rye;  in  either  country  the  early  summer  months. 
May  to  July,  are  those  in  which  the  disease  is  met  with.  In 
America,  in  addition  to  the  attacks  in  early  summer,  a  severe 


ASTHMA  249 

form  of  the  complaint  is  met  with  in  the  autumn,  the  so-called 
"autumnal  catarrh,"  which  is  produced  by  the  pollen  of  cer- 
tain grasses  which  flower  at  this  season  of  the  year. 

The  pollen  of  the  various  plants  in  question  contains,  as 
demonstrated  by  Professor  Dunbar,  an  active  protein, 
soluble  in  saline  solution,  minute  doses  of  which  produce  in 
sensitive  subjects  the  symptoms  of  the  malady,  and  must 
therefore  be  regarded  as  its  cause.  The  pollen  floating  in  the 
air  finds  its  way  into  the  eye  or  nose,  its  protein  is  extracted 
and  absorbed,  and  thus  gives  rise  to  the  lachrymatibn,  sneez- 
ing, and  running  from  the  nose  which  form  so  familiar  a 
picture.  In  a  smaller  proportion  of  cases,  and  generally  some 
hours  later  during  the  night,  an  attack  of  asthma  follows. 

(5)  Nasal  asthma,  as  the  name  implies,  comprises  that 
group  of  cases  to  which  we  have  already  alluded,  in  which  the 
asthma  has  been  traced  to  a  definite  source  of  irritation 
within  the  nose.  In  such  cases  relief  may  be  given  by  opera- 
tive treatment,  a  question  to  which  we  shall  recur  later. 

(6)  The  term  peptic  asthma  includes  those  cases  in  which 
the  asthmatic  attacks  bear  a  definite  relation  to  gastro- 
intestinal irritation,  flatulent  distension  of  the  stomach,  and 
so  forth,  and  it  is  not  to  be  doubted  that  many  cases  of 
asthma  met  with  are  in  this  sense  manifestations  of  dyspepsia. 
The  class  of  peptic  asthma  may,  however,  with  great  prac- 
tical utility  be  enlarged.  Thus,  Salter^*  expressed  the  belief 
that  the  introduction  of  food  frequently  gave  rise  to  asthma, 
not  by  irritation  of  the  alimentary  canal,  but  by  absorption 
into  the  veins  of  materials  perfectly  normal  to  the  stage  of 
the  digestive  process,  but  which  in  the  asthmatic  stimulated 
the  unduly  sensitive  pulmonary  nervous  system  to  produce 
spasm;  and  in  this  connection  we  must  recall  that  certain 
articles  of  diet,  especially  saccharine  substances  and  other 
carbohydrates,  prove  unsuitable  to  some  asthmatics.  We 
have  already  alluded  to  cases,  chiefly  of  children,  in  which 
the  patient  is  anaphylactic  to  the  protein  of  certain  foods. 
In  the  gouty  subject,  the  blood  circulating-  through  the 
nervous  centres  is  charged  with  imperfectly  changed  and 
effete  material,  and  attacks  of  "gouty  asthma"  may  thus 
originate.  It  may  well  be  believed,  too,  that  in  cases  of 
loaded  colon  asthma  is  sometimes  set  up  by  the  absorption 
of  toxines  and  putrefactive  matters, 


250  DISEASES    OF   THE  LUNGS   AND   PLEURA 

(7)  Cardiac  asthma  belong-s  to  a  different  group  from  that 
which  we  have  been  considering-.  It  is  in  reahty  a  con-se- 
quence of  heart  failure,  whether  the  resuh  of  fatty  and  senile 
degenerations  or  of  valvular  disease  with  incomplete  or  dam- 
aged compensation.  Most  commonly  the  attacks  occur  during 
sleep  or  towards  the  morning,  when  the  blood-pressure  and 
general  vitality  are  low.  Signs  of  passive  congestion  of  the 
bases  of  the  lungs,  more  especially  on  one  side,  may  generally 
be  detected,  and  some  blood-staining  of  sputa  is  not  in- 
frequently observed  to  follow  the  attack. 

(8)  In  urmnic  asthma  oedema  of  the  lungs  is  generally 
present.  We  have  seen  cases,  however,  in  which  the  morbid 
material  in  the  blood  seemed  to  be  more  directly  the  excitant, 
thus  bringing  them  more  into  line  with  true  asthma. 

Symptomatology. — The  subjects  of  asthma  present,  in  the 
advanced  periods  of  their  malady,  a  characteristic  physiog- 
nomy. Thin,  of  nervous  temperament,  grave-featured,  with 
sHghtly  depressed  angles  of  the  mouth,  high-shouldered  and 
round-backed,  they  carry  the  impress  of  suffering  in  feature 
and  build,  and  one  is  sometimes  surprised  at  the  power  of 
work,  keenness  of  wit,  and  capacity  for  enjoyment  with  which 
these  persons  are  gifted.  It  requires  many  severe  attacks, 
however,  to  bring  about  these  characteristic  appearances,  and 
in  the  intervals  between  the  earHer  seizures  there  may  be 
nothing  in  the  physiognomy  of  the  patient  symptomatic  of 
asthma.  In  the  later  periods  of  the  disease,  and  at  an  earlier 
date  after  a  recent  attack,  there  may  be  quickened  breathing, 
accompanied  by  slight  wheezing,  very  perceptible  to  the 
observer,  although  the  patient  would  consider  himself  quite 
free  from  dyspnoea. 

There  is  another  type  of  asthmatic,  which  may  perhaps  be 
distinguished  as  the  gouty,  in  which  the  patient  is  full-fleshed, 
with  excess  of  adipose  tissue,  especially  about  the  abdomen, 
the  general  build  suggesting  the  short-necked  "  apoplectic " 
subject,  rather  than  the  thin  stork-like  aspect  of  the  victim  of 
the  more  neurotic  form  of  the  disease.  The  distinction  is 
one  of  considerable  practical  importance. 

■  The  Attack. — Patients  with  true  spasmodic  asthma  may  be 
seized  at  any  time  of  the  day  or  night,  but  more  frequently  the 
attack  comes  on  at  night  after  the  first  sleep.  A  certain  feel- 
ing of  oppression  about  the  chesty  attended  perhaps  with  some 


ASTHMA  251 

wheezing,  may  give  warning  of  the  approaching  seizure ;  more 
rarely  the  attack  comes  on  almost  instantaneously,  and  with- 
out warning.  The  sense  of  oppression  may  partially  awaken 
the  patient  or  give  rise  to  some  disturbing  dream,  and  he 
either  starts  up  in  a  fright  with  the  fit  of  dyspnoea  full  upon 
him,  or  more  gradually  awakens  to  the  increasing  difificulty 
of  respiration. 

A  severe  attack  of  asthma  is,  to  the  inexperienced,  truly 
alarming  to  witness;  the  expression  of  face,  pale,  staring, 
anxious,  and  distressed;  the  mouth  slightly  opened,  its  corners 
twitched  downwards  with  each  brief  effort  at  inspiration, 
whilst  the  neck  muscles  start  forward  in  violent  convulsive 
action.  The  shoulders  are  rounded,  the  body  inclined  for- 
wards, and  the  hands  rigidly  grasp  some  firm  object  to  fix  the 
scapular  and  humeral  attachments  of  the  chest  muscles.  With 
the  powerful  inspiratory  jerk  thus  effected  the  thorax  is  lifted 
en  masse,  but  the  deepening  of  the  supraclavicular  hollows 
and  depressed  lower  thorax,  sternum,  and  epigastrium,  bear 
witness  to  the  small  penetration  of  air  into  the  lungs  in 
response  to  all  this  effort.  Expiration  is  still  more  difficult, 
for  the  expiratory  force  is,  so  to  speak,  beaten  in  detail.  The 
air-current  in  inspiration  starts  towards  points  of  obstruction 
with  a  force  proportional  to  expansion.  In  expiration,  how- 
ever, each  infundibular  current  is  obstructed  whilst  3/et  a 
feeble  stream;  the  expiration  is  thus  prolonged,  laboured,  and 
but  feebly  and  gradually  effected,  when,  without  a  moment's 
pause,  the  quick,  short,  powerful  inspiratory  jerk  again  takes 
place.  The  actual  number  of  respirations  per  minute  may  not 
be  increased,  and  is  sometimes  diminished;  the  pulse  is,  how- 
ever, invariably  quick,  small,  and  often  irregular  and  vacillat- 
ing, and  there  may  not  infrequently  be  noticed  a  distinct  hesita- 
tion or  failure  of  the  pulse  wave  with  each  inspiratory  effort. 

In  earlier  attacks,  more  especially,  there  is  great  restless- 
ness and  frequent  change  of  posture,  with  a  disposition  to 
lose  self-control  in  the  desperation  of  air-hunger.  But  the 
experienced  asthmatic  assumes  and  maintains  some  favourite 
attitude.  The  severity  of  attack  may  last  from  a  few  minutes 
to  many  hours,  but  it  will  be  observed  that  even  in  the  most 
urgent  cases  there  are  intervals  of  partial  relaxation,  during 
which  the  breathing  becomes  more  easy,  to  be  followed  shortly 
by  full  intensity  of  spasm. 


252  DISEASES    OF   THE   LUNGS   AND   PLEUR.E 

Towards  the  close  of  the  attack  cough  comes  on,  and  with 
the  expectoration  of  some  viscid  mucous  pellets  the  dyspnoea 
is  greatly  mitigated.  The  body  temperature  during  the  seizure 
is  depressed,  cold  sweats  break  out  over  the  forehead,  and 
the  features  become  dusky  and  partially  cyanosed.  In  very 
severe  cases  capillary  haemorrhages  into  the  conjunctiva  have 
been  noticed  (Walshe).  The  mind  rarely  becomes  even  for  a 
moment  clouded,  and  only  in  early  cases  does  the  patient 
sometimes  lose  that  self-control  which  is  of  so  much  service 
to  him  in  the  struggle.  The  urine  is  generally  abundant,  pale, 
and  of  low  specific  gravity,  and  the  solid  constituents  are 
lessened  (Ringer).  The  subsidence  of  the  attack  is  generally 
gradual, but  sometimes  almost  sudden,  with  more  or  less  expec- 
toration, and  the  exhausted  sufferer  falls  into  a  troubled  sleep. 

Physical  Signs. — During  the  attack  the  thorax  is  semi- 
expanded,  with  but  little  movement  in  response  to  the  respira- 
tory efforts;  the  percussion  note  is  resonant,  and  more  or  less 
of  the  emphysema  type.  Careful  percussion  is,  however,  im- 
possible and  useless.  Auscultation  reveals  but  little  or  no 
breath-sound,  beyond  a  short  wheeze  in  response  to  the  sharp 
inspiratory  jerk,  whilst  the  expiratory  murmur  is  wholly 
obscured  by  prolonged  cooing  sibili  of  varying  note.  The 
heart's  impulse  can  be  best  felt,  and  sometimes  strongly  so,  at 
or  below  the  ensiform  cartilage. 

The  amount  of  expectoration  varies  with  the  intensity  and 
duration  of  the  attack.  The  most  characteristic  expectoration 
consists  of  Httle  pellets  about  the  size  of  a  pea,  and  "  of  the 
consistence  of  jelly  or  thick  arrowroot,  of  a  pale  grey  colour, 
of  an  opalescent  transparency,  and  a  saltish  taste"  (Salter). 
When  carefully  examined  and  unfolded  these  pellets  will  be 
found  to  contain  casts  of  the  finest  bronchial  tubes,  con- 
stituting the  peculiar  formations  known  as  Curschmann's 
spirals,  which  have  already  been  described  (p.  74).  In  almost 
all  cases,  too,  on  careful  search,  especially  if  the  sputum  has 
been  kept  for  some  hours  before  examination,  Charcot-Leyden 
crystals  will  be  met  with  (p.  75),  sometimes  within  the  spirals, 
sometimes  free.  As  already  indicated,  neither  crystals  nor 
spirals  can  be  regarded  as  pathognomonic  of  the  disease.  The 
asthmatic  sputum  contains  in  addition  large  numbers  of 
eosinophile  cells,  and  a  considerable  increase  of  these  cells 
will  also  be  found  in  the  blood  during  the  asthmatic  attack : 


ASTHMA  253 

their  number  may  reach  as  high  as  25  per  cent,  of  the  total 
leucocyte  count. 

Slight  haemoptysis  is  occasionally,  but  rarely,  observed  in 
severe  cases  of  asthma.  Where  pulmonary  oedema  or  con- 
gestion follows  upon  a  severe  paroxysm  the  expectoration  is 
more  abundant,  consisting  of  a  frothy,  sometimes  sHghtly 
blood-stained,  mucus. 

After  a  serious  attack  of  asthma  much  prostration  and 
fatigue  are  experienced  from  the  severity  and  duration  of  the 
struggle  and  from  want  of  food  and  sleep.  These  symptoms 
will  soon  be  recovered  from,  but  renewed  attacks  commonly 
ensue  at  short  intervals,  until  at  the  end  of  a  certain  series 
the  malady  appears  to  be  for  a  time  exhausted. 

More  or  less  wheezing  rhonchi  generally  persist  for  some 
hours  or  days,  and  in  severe  cases  it  is  common  to  find 
at  the  bases  some  fine  bubbling  rales.  The  percussion  signs 
and  chest  conformation  at  this  period  are  those  of  acute 
pulmonary  emphysema,  varying  in  degree  according  to  the 
severity  of  the  attack.  After  a  succession  of  attacks  there  is 
an  amount  of  emphysema  of  the  lungs,  with  oedema  of  their 
bases,  and  fatigue  of  the  right  ventricle  of  the  heart,  which 
requires  some  time  and  treatment  to  remove.  From  single 
attacks,  even  although  very  severe,  the  patient  after  a  night's 
rest  may  feel  quite  restored.  In  other  instances  the  attacks 
are  brief,  but  return  each  night;  these  are  usually  cases  in 
which  the  paroxysm  is  controlled  by  some  remedy,  and 
although  jaded  by  disturbance  of  rest,  such  patients  are  able 
to  pursue  their  daily  w^ork  or  pleasure. 

Periodicity  of  seizure  is  usually  a  marked  feature  of  asthma. 
The  seizures  may  be  daily,  weekly,  monthly,  yearly,  or  at 
other  tolerably  regular  intervals.  A  patient  may  suffer  a  series 
of  daily  seizures,  and  then  enjoy  a  certain  interval  of  freedom. 
It  will  be  observed,  however,  with  asthma,  as  with  epilepsy, 
that  as  time  advances  the  attacks,  unless  influenced  otherwise 
by  treatment,  tend  to  become  more  frequent,  although  less 
severe,  a  number  of  minor  seizures  being  interpolated  between 
the  more  regular  attacks,  the  gradually  increasing  emphysema 
rendering  the  intervals  less  and  less  defined. 

In  the  earlier  years  of  true  spasmodic  asthma  patients  are 
able  in  the  intervals  of  attack  to  take  part  in  sports  and 
exercises,  which  make  large  demands  upon  the  respiratory 


254  DISEASES   OF  THE  LUNGS   AND   PLEURA 

powers.  As  the  disease  continues  from  year  to  year,  however, 
it  gradually  entails  other  symptoms  significant  of  definite  pul- 
monary lesions;  shortness  of  breath,  and  more  or  less  wheez- 
ing continue  through  the  intervals;  the  physical  signs  of 
emphysema  remain  permanent,  and  visceral  congestion  and 
associated  dyspeptic  symptoms  become  manifested.  The 
heart  especially  suffers,  its  right  ventricle  becomes  dilated, 
systemic  venous  fulness  ensues,  and,  finally,  oedema  of  extremi- 
ties, abdominal  dropsy,  with  enlarged  and  hardened  liver  and 
albuminous  urine,  supervene  (see  chapter  on  Emphysema, 
p.  271).  In  a  certain  number  of  cases  of  asthma,  on  the  other 
hand,  the  lungs  give  way,  an  atrophic  form  of  emphysema 
appearing,  which  proceeds  to  coalescence  of  vesicles  with 
adjacent  pulmonary  fibrosis.  Should  this  occur  at  one  or  both 
apices,  the  condition  may  readily  be  mistaken  for  chronic 
phthisis.  In  yet  other  cases  pulmonary  tuberculosis  super- 
venes, with  the  onset  of  which  the  paroxysms  of  asthma  may 
wholly  cease. 

The  Prognosis  of  asthma  proper  is  estimated  by  ascertaining 
the  amount  of  physical  damage  which  the  patient  has  as  yet 
sustained  to  lung  and  heart,  for  it  is  through  complications  re- 
ferable to  these  org-ans  that  life  is  commonly  shortened.  Asthma 
per  se  never  kills,  for  when  the  paroxysm  actually  threatens 
life  the  spasm  yields;  nor  is  the  asthmatic  prone  to  some  of 
the  diseases,  such  as  cancer,  tubercle,  Bright's  disease,  which 
in  others  shorten  life.  His  own  peculiar  malady  is  enough 
for  him  to  contend  with,  and  it  enforces  upon  him  a  compara- 
tively sheltered  life.  Asthma  is,  in  fact,  compatible  with  a 
life  of  medium  length  and  of  much  usefulness,  but  of  much 
suffering  and  self-denial.  Family  longevity  should  be  inquired 
into  in  regard  to  prognosis.  Infantile  asthma,  especially,  if 
not  definitely  inherited,  sometimes  ceases  at  about  puberty, 
and  asthma  of  a  gouty  or  influenzal  origin  is  frequently  cured 
by  appropriate  treatment. 

Treatment. — There  is  no  disease  which  is  so  extensively 
"  quacked "  as  asthma.  Persons  who  are  the  victims  of  the 
pure  neurosis  are  amongst  the  most  restless  of  mankind; 
their  temperaments  are  often  of  the  highly-strung,  nervous 
type,  and  whilst  they  are  gifted  with  much  courage,  endurance, 
and  determination,  they  possess  little  faith,  many  friends,  and 
much  credulity.     The  practitioner  who  would  guide  these  suf- 


ASTHMA  255 

ferers  must  himself  have  clear  opinions  respecting  the  salient 
points  in  treatment,  and  must  be  patient  in  hearing  and 
endeavouring  to  understand  the  experience  of  each  individual. 
The  treatment  of  asthma  may  be  considered  under  the  fol- 
lowing headings : 

1.  Specific  Treatment. — When  consulted  by  an  asthmatic 
patient,  we  must  recall  what  we  have  said  as  to  the  aetiology 
of  the  disease,  remembering-  that  in  a  proportion  of  cases  it 
is  the  result  of  sensitisation  to  some  particular  protein.  Care- 
ful inquiry  must  accordingly  be  made  as  to  the  patient's  asso- 
ciation with  horses,  cats,  or  cattle,  and  the  use  of  feather  beds 
or  pillows.  The  question  of  pollen  irritation  must  also  be 
considered.  In  those  cases  especially  in  which  the  attacks 
have  commenced  in  infancy,  the  possibility  of  sensitisation  to 
some  special  food  protein  must  be  borne  in  rnind,  and  some- 
times the  withdrawal  of  white-of-egg  from  the  diet,  or  the 
substitution  of  goats'  for  cows'  milk,  will  effect  a  great  im- 
provement. If  the  asthma  is  connected  with  bronchitis,  the 
possible  cause  must  be  looked  for  in  bacterial  protein.  After 
due  observation  such  suspected  factors  may  be  scrutinised  by 
the  pathologist  with  the  aid  of  the  cutaneous  test,  and  the 
particular  protein,  if  any,  discovered.  If  the  malady  be  traced 
to  a  food  protein,  the  special  food  must  be  eliminated  from 
the  diet,  to  be  afterwards  introduced  tentatively  and  in  regu- 
lated quantities,  with  a  view  to  establishing  immunity;  if  to  an 
animal,  pollen,  or  bacterial  protein,  desensitisation  may  be 
effected  by  gradually  increasing  doses  of  the  appropriate 
vaccine. 

2.  Climatic  Treatm^ent. — This  consists,  in  the  first  place,  in 
the  removal  of  the  patient  from  those  external  surroundings 
which  appear  to  have  led  up  to  his  attack,  to  more  favourable 
conditions  of  residence — e.g.,  from  a  dusty  to  a  pure  atmo- 
sphere; from  a  cold,  damp  house  or  locality  to  a  dry  soil  and  a 
well-ventilated  and  cellared  house,  with  no  trees  in  the  imme- 
diate vicinity. 

To  tell  with  precision  what  locality  will  suit  a  given  indi- 
vidual with  asthma  is  very  difficult.  There  are  idiosyncrasies 
in  each  case,  and  no  asthmatic  should  burden  himself  with  a 
house  until  he  has  first  tested  the  locality  by  residence  there 
for  some  time.  There  are,  however,  certain  climates  which 
are  most  likely  to  prove  beneficial  for  asthma  patients. 


256  DISEASES    OF   THE  LUNGS   AND   PLEURAE 

(a)  Bournemouth,  the  St.  George's  Hill  neighbourhood  of 
Weybridge,  and  the  Farnborough  and  Bagshot  districts,  with 
their  sandy  soil  and  pine  vegetation,  may  be  named  amongst 
English  localities  as  places  which  are  under  all  circumstances 
preferable  to  cold,  damp  neighbourhoods,  and  which  are 
peculiarly  adapted  for  the  purest  forms  of  asthma  in  which 
the  neurosis  is  most  marked.  Abroad,  Arcachon  may  be  simi- 
larly recommended  during  the  winter  and  spring  months. 

(b)  Torquay,  St.  Mary  Church,  Pau,  Cimiez,  Hyeres,  Men- 
tone,  Algiers,  Algeciras,  Grand  Canary,  and  Santa  Cruz 
(Teneriffe)  may  be  mentioned  as  varied  resorts  adapted  for 
winter  residence  for  the  mixed  catarrhal  forms  of  asthma. 

(c)  Experience  teaches  a  certain  number  of  asthmatics  that 
a  sea  voyage  does  most  for  them,  and  in  such  cases  the  cure 
may  best  be  thus  started.  This  plan  is  especially  suited  for 
cases  of  dust  and  hay  asthma,  as  also  for  those  in  which  the 
first  seizure  has  been  traceable  to  a  nervous  system  broken 
down  by  anxiety,  overwork,  or  excesses. 

(d)  In  young  subjects,  with  as  yet  no  marked  emphysema, 
the  pure  rarefied  airs  of  St.  Moritz,  Davos,  Montana,  and 
Arosa  yield  good  results  in  winter,  and  in  the  hot  months  they 
may  be  resorted  to  with  advantage  by  some  older  patients.  In 
this  connection  we  may  perhaps  add  that  we  have  known  an 
asthmatic  subject  to  remain  quite  well  when  residing  for  some 
years  at  Arequipa  in  Peru,  at  an  altitude  of  12,000  ft.,  but  the 
attacks  returned  as  soon  as  he  again  came  to  live  at  an 
ordinary  level.  Ilkley,  Ben  Rhydding,  Dartmoor,  Malvern, 
and  Hindhead,  are  suitable  situations  in  the  summer  season 
for  convalescent  asthmatics. 

(e)  A  considerable  number  of  asthma  patients  do  best  in 
towns,  being  chiefly  those  who  have  removed  from  more  or 
less  damp  localities  surrounded  by  trees.  As  a  rule  asthmatics 
should  repair  to  large  towns  or  seaside  resorts  in  the  late 
autumn,  and  perhaps  the  late  spring. 

3.  Medicated  Airs  and  Baths. — In  cases  of  catarrhal  asthma, 
in  those  of  influenzal  origin,  and  in  those  in  which  a  gouty 
element  or  an  association  with  eczematous  eruptions  or 
urticaria  can  be  observed,  a  summer  course  of  three  or  four 
weeks'  duration,  at  Mont  Dore,  Aix-les-Bains,  Allevard-les- 
Bains,  or  Dax,  but  especially  at  the  first-named,  will  often  be 
attended    with    long-continued    benefit.      Minute    traces    of 


ASTHMA  257 

arsenic  mingled  with  the  vapours  at  the  Mont  Dore  baths  are 
regarded  as  answerable  for  their  good  effects,  and  at  Allevard 
the  sprayed  air  of  the  inhalation  chambers  is  decidedly  charged 
with  sulphuretted  hydrogen.  This  latter  treatment  is  most 
adapted  for  the  chronic  bronchitic  forms  of  the  disease;  at 
the  other  places  probably  the  sweating  of  the  skin  and  bron- 
chial membranes  constitutes  the  chief  remedial  factor.  The 
course  at  one  of  these  bathing  resorts  should  be  followed  up 
by  an  after-cure  at  some  more  bracing  place,  such  as  Eaux 
Bonnes,  Cauteret,  Spa,  or  the  Swiss  mountains,  or,  in  this 
country,  at  Ilkley,  Ben  Rhydding,  Braemar,  or  other  moorland 
districts  of  Yorkshire  or  Scotland.  A  course  of  Turkish  baths 
for  those  who  cannot  go  abroad  sometimes  proves  of  great 
service.  We  have  in  some  instances  seen  much  benefit  from  the 
use  of  the  compressed-air  baths  at  the  Brompton  Hospital 
(see  p.  281),  but  we  can  only  mention  this  as  an  empirical  fact. 
4.  Regulation  of  the  Digestive  Function. — Not  less  impor- 
tant than  the  selection  of  a  suitable  climate  is  the  careful  regu- 
lation of  the  digestive  functions  of  the  asthmatic.  In  not  a 
few  cases  the  cause  of  the  attacks  is  associated  with  the 
habitual  ingestion  of  an  excessive  quantity  of  food,  and  if  this 
be  diminished  the  frequency  of  the  paroxysms  will  be  greatly 
curtailed.  In  other  instances  the  exciting  cause  is  some  error 
in  digestion  which  requires  careful  regulation  and  attention, 
and  in  all  cases  the  digestive  function  ultimately  suffers,  and 
reacts  unfavourably  upon  the  spasmodic  troubles.  Very  slow 
eating  should  be  strictly  enjoined,  and  the  staple  food,  includ- 
ing a  moderate  quantity  of  meat,  should  be  taken  at  the  mid- 
day meal,  only  the  lightest  possible  diet  being  allowed  later  in 
the  day.  In  some  cases  where  farinaceous  foods  ferment,  a 
more  nitrogenous  dietary,  approximating  to  the  "  Salisbury  " 
system,  may  be  recommended.  In  all  cases  it  is  wise  to  sub- 
stitute for  bread  with  the  meat  meals  unsweetened  rusks,  or 
Huntley  and  Palmer's  breakfast  biscuits,  or  baked  toast.  In 
cases  in  which  there  is  excess  of  uric  acid  or  urates,  and  a 
disposition  to  flatulent  dyspepsia,  cutaneous  eruptions,  and  so 
forth,  sweet  wines,  raw  fruits,  sugar,  cooked  butter,  and 
pastry  should  be  excluded  from  the  dietary.  An  alkaline 
bitter  may  often  be  taken  twice  a  day  with  great  advantage 
when  the  tongue  is  red  and  coated,  bismuth  being  added  when 
there  is  gastrodynia. 

17 


258  DISEASES    OF   THE  LUNGS   AND   PLEURA 

The  liver  and  bowels  require  careful  attention,  very  small 
doses  of  mercurial  being  useful  from  time  to  time,  whilst  in 
these,  as  in  all  neurotic  subjects,  large  doses  of  this  drug  are 
positively  harmful.  Calomel,  given  occasionally  in  half-grain 
doses  at  night,  is  esipecially  valuable.  A  sulphate  of  soda 
saline  should  be  taken  in  hot  fluid  in  the  morning  after  each 
dose  of  mercurial.  In  other  cases  a  teaspoonful  of  Pulvis 
rhei  co.  at  bedtime  will  prove  beneficial.  If  the  rectum  be 
loaded,  relief  should  be  effected  by  enemata  rather  than  by 
violent  aperients. 

When  the  tongue  is  fairly  clean,  or  at  all  events  when  the 
practitioner  is  satisfied  that  the  primce  vice  are  acting  efficiently, 
a  course  of  arsenic  is  often  of  great  service. 

5.  Attention  to  Other  Sources  of  Peripheral  Irritation. — 
What  we  have  urged  in  regard  to  the  digestive  functions 
applies  also  to  other  organs,  and  if  any  definite  source  of 
peripheral  irritation  exists,  it  should  receive  attention.  The 
condition  of  the  nasal  cavities  should  always  be  carefully 
investigated,  since  improvement,  sometimes  even  permanent 
cure,  has  resulted  from  the  removal  of  a  polypus  or  the  treat- 
ment of  sinus  suppuration  or  some  other  obvious  defect.  In 
the  absence  of  any  such  gross  lesions  we  should  hesitate  to 
advise  prolonged  or  serious  nasal  treatment,  for  although 
transitory  amendment  may  follow  upon  the  shock  or  distrac- 
tion of  any  operative  measure,  no  benefit  of  a  permanent 
character  results  unless  there  be  some  definite  condition  to  be 
amended.  The  application,  however,  of  the  galvanic  cautery 
to  various  points  upon  the  nasal  mucous  membrane,  especially 
of  the  septum,  not  uncommonly  gives  temporary  rehef,  and 
as  the  procedure  is  a  simple  one,  it  may  be  tried  in  obstinate 
cases. 

Treatment  of  the  Paroxysm.— Most  commonly  the  practi- 
tioner makes  his  first  acquaintance  with  the  asthmatic  patient 
when  the  paroxysm  is  at  its  height.  A  few  questions  as  to 
duration  of  attack,  preceding  attacks,  and  circumstances  and 
symptoms  immediately  antecedent  to  the  present  seizure,  will 
suffice  to  direct  a  rational  and  safe  treatment. 

When  irritating  matter  is  present  in  the  stomach,  whether 
in  the  shape  of  undigested  food  or  irritant  catarrhal  mucus, 
an  emetic  of  twenty  grains  of  ipecacuanha,  or  a  subcutaneous 
injection  of  j\  to  ^  grain  of  apomorphia,  will  give  prompt 


ASTHMA  259 

relief  by  its  removal.  Warm  water  with  a  little  carbonate  of 
soda  should  be  given  to  encourage  a  thorough  clearance  of 
the  stomach. 

In  cases  of  catarrhal  asthma,  during  the  paroxysm,  ten 
minims  of  ipecacuanha  wine,  with  fifteen  minims  of  ethereal 
tincture  of  lobelia,  given  every  half-hour  for  two  or  three 
doses,  then  every  hour  or  two  hours,  will  often  prove  service- 
able. The  hquid  extract  of  grindelia  robusta  (u.s.p.)  in  fifteen- 
minim  doses  may  be  sometimes  substituted  for  the  lobelia. 

In  the  choice  of  sedative  remedies,  a  careful  judgment  must 
first  be  arrived  at  as  to  the  amount  of  tubal  catarrh  and  secre- 
tion present.  The  well-known  "cures"  of  asthma  appear  to 
owe  their  efficacy  partly  to  an  evacuant,  partly  to  a  sedative, 
action.  The  fumes  from  burning  the  "  Himrod,"  "  Potters," 
"  Green  Mountain,"  "Chester"  and  other  similar  powders,  first 
excite  more  or  less  cough,  after  which,  and  especially  if  expec- 
toration be  effected,  the  spasm  yields.  A  powder  containing 
four  drachms  of  powdered  stramonium  leaves,  two  drachms 
of  powdered  nitre,  a  similar  quantity  of  aniseed,  and  five 
grains  of  tobacco  is  a  very  efficacious  combination,  much  used 
at  the  Brompton  Hospital.  A  teaspoonful  of  this  powder 
should  be  made  into  a  conical  heap  on  a  plate,  lighted  at  the 
summit,  and  the  fumes  inhaled  through  a  large  inverted  funnel. 
In  the  more  purely  nervous  forms  of  asthma,  when  as  yet  there 
is  no  secretion  present,  sedative  remedies  must  be  used. 

By  closely  shutting  the  room  and  filling  it  with  the  fumes 
of  nitre*  the  asthmatic  sufferer  will  sometimes  gain  relief  and 
rest.  Salter  considered  nitre  thus  used  a  powerful  sedative,  but 
it  must  be  confessed  that  its  mode  of  action  remains  obscure. 
Its  efficacy,  however,  in  certain  cases  is  unquestionable. 

In  other  cases  speedy  relief  has  been  obtained  by  spray- 
ing the  nasal  cavities  with  a  solution  of  adrenalin  chloride, 
I  in  2,000,  or  by  the  subcutaneous  injection  of  i  to  5  minims 
of  the  I  in  1,000  solution,  the  adrenalin  paralysing  for  a  time 
the  nerve  endings,  thus  allowing  the  bronchioles  to  dilate. 
Extract  of  the  posterior  lobe  of  the  pituitary  body,  which  is 

*  Take  four  ounces  of  nitrate  of  potash  dissolved  in  half  a  pint  of  boil- 
ing water,  pour  out  into  a  soup  plate,  immerse  in  the  solution  thick  blotting- 
paper,  dry,  and  cut  in  squares  of  four  inches.  A  little  chlorate  of  potash, 
about  half  a  drachm  to  the  ounce,  may  sometimes  be  usefully  combined 
with  the  nitre. 


26o  DISEASES   OF   THE   LUNGS   AND   PLEUR/E 

stated  to  act  like  adrenalin,  but  to  have  a  more  lasting  effect, 
is  helpful  in  some  patients. 

In  the  full  height  and  intensity  of  attack  nitrite  of  amyl, 
iodide  of  ethyl,*  or  chloroform,  may  be  inhaled  with  temporary 
advantage,  and  the  true  spasmodic  nature  of  the  affection  will 
be  well  demonstrated  by  the  complete  subsidence  of  the  sibilus 
under  the  influence  of  chloroform.     The  effect  of  these  drugs 
is,  however,  as  a  rule  very  evanescent,  and  their  use  is  only 
desirable  to  mitigate  extreme  symptoms.     Strong  coffee  some- 
times distinctly  relieves  spasm,  and  "eupnine"  a  solution  con- 
taining caffeine  and  iodine,  may  be  given  in  drachm  doses  in 
water,  and  repeated  in  half  an  hour,  with  a  like  result.     Nitro- 
glycerine and  nitrite  of  sodium  have  also  been  recommended. 
Joy's    cigarettes    and    Savory    and    Moore's    datura    tatula 
cigarettes  will,  provided  the  patient  can  inhale  the  smoke  into 
the  lungs,  in  many  cases  give  great  reHef  to  the  urgent  symp- 
toms, their  efficacy  being  due  to  stramonium  and,  probably, 
some  opium  combined.     Another  remedy  much  used  by  the 
public  is  "  Dr.  Tucker's  Asthma  Specific,"  a  liquid  which  is 
inhaled  as  a  very  fine  spray  from  a  vaporiser  or  atomiser,  and 
which  is  often  effective  in  relieving  the  spasm.     An  analysis  of 
its  contents,  made  by  Dr.  Willcox,^"  showed  each  fluid  ounce 
to  contain  cocaine  2'28  grains,  atropine  o'S/  grain,  sodium 
nitrite  i5'25  grains,  a  certain  quantity  of  balsam  or  gum-ben- 
zoin,  between  20  and  30  per   cent,  by  volume   of   glycerin, 
together  with  traces  of  mineral  ingredients,  vegetable  colour- 
ing matter,  and  so  forth.     This  mixture  when  inhaled  often 
gives  great  relief,  but  it  contains  potent  drugs,  and  its  use  has 
sometimes    been   attended   with    disquieting    symptoms.      It 
should  be  employed,  therefore,  with  caution,  the  tendency  to 
its  use  becoming  a  habit  being  also  remembered.    An  analogous 
remedy  is  the  Xebula  hyoscinse  co.  of  the   British  Pharma- 
ceutical Codex. 

In  severe  cases  an  almost  unfailing  remedy  is  morphia  used 
subcutaneously  in  doses  of  from  ^  to  |  grain.  Morphia  is  a 
remedy  which,  from  the  immediate  relief  it  affords,  is  apt  to 
be  given  somewhat  recklessly,  and  to  be  called  for  per- 
emptorily by  the  patient,  without  counting  the  cost  in  after 
consequences.     The  drug  should  be  used  with  caution,  for 

*    Convenient  five-drop  capsules  of  this  drug,  enclosed  m  silk,  similar  to 
those  of  nitrite  of  amyl,  can  be  obtained. 


ASTHMA  261 

not  a  few  casualties  have  arisen  from  its  employment.  In 
catarrhal  cases  it  should  not  be  employed,  and  in  the  most 
purely  neurotic  cases,  for  the  relief  of  which  it  is  best  adapted, 
it  is  a  demoralising  remedy.  In  fact,  the  employment  of  mor- 
phia in  asthma  is  exactly  comparable  to  its  use  in  neuralgia; 
prompt  in  relieving,  it  lowers  nerve  tone,  hampers  secretion, 
and  increases  liability  to  recurrence.  The  tendency  of  the 
patient  is  to  have  recourse  increasingly  to  its  use  for  trivial 
attacks,  until  custom  renders  a  large  and  dangerous  dose 
necessary.  In  certain  cases  the  drug  is  required;  they  are 
exceptional,  however,  and  the  most  strenuous  efforts  should 
be  made  by  the  practitioner  in  such  cases  to  remove  his  patient 
out  of  the  conditions  to  which  the  asthma  appears  attributable. 
Hypodermic  injections  of  atropine,  yot  to  ^  grain,  either 
alone  or  in  combination  with  morphia,  are  sometimes  useful. 
More  recently  heroin  has  been  used  with  good  results,  in  doses 
of  1^2-  to  I  grain  of  the  hydrochloride,  given  subcutaneously 
and  repeated  in  an  hour  if  necessary.  But  here  again  there 
is  a  danger  of  the  use  of  the  drug  degenerating  into  a  habit. 

Chloral  in  full  doses  of  ten  or  twenty  grains  every  four  or 
six  hours  is  also  efficacious  in  pure  asthma,  and  it  may  be 
used  in  the  catarrhal  forms;  its  administration,  however, 
requires  strict  medical  supervision  and  very  precise  directions. 
It  may  sometimes  usefully  be  given  in  small  doses  in  com- 
bination with  iodide  of  potassium  and  other  drugs. 

In  cases  of  catarrhal  asthma  especially,  and  in  some  other 
less-defined  cases,  one  of  the  most  valuable  remedies  is  iodide 
of  potassium,  in  combination  with  stramonium.  The  iodide 
is  especially  indicated  in  those  cases  in  which  there  is  a  nightly 
paroxysm,  but  in  which  there  is  also  a  perceptible  dyspnoea  and 
wheezing  throughout  the  day.  Three  to  five  grains  of  iodide 
of  potassium,  with  |  grain  of  extract  of  stramonium,  should 
be  given  every  three  or  four  hours  during  the  day,  e.g.,  8  a.m., 
12  noon,  3  p.m.,  6  p.m.,  9  p.m.,  so  as  to  administer  some  fifteen 
to  thirty  grains  of  the  salt  and  one  to  two  grains  of  the 
extract  by  bedtime.  The  addition  of  small  doses,  2V  grain,  of 
apomorphia  to  the  mixture  is  sometimes  helpful.  After  a  day 
or  two  when  the  patient  suffers  slight  iodism,  and  the  physio- 
logical effect  of  the  stramonium  upon  pupil  and  throat  becomes 
apparent,  the  medicine  may  be  continued  in  half  doses.  In 
the  many  cases  in  which  this  line  of  treatment  proves  valuable 


262  DISEASES   OF  THE   I.UNGS   AND   fLEUR^ 

it  should  be  commenced  on  the  first  approach  of  asthma 
phenomena.  Another  remedy  which  we  have  found  of  use  in 
warding  off  asthmatic  attacks  is  "  GrindeHne,"  which  contains 
small  doses  of  grindelia  robusta,  euphorbia,  liq.  trinitrini, 
and  potassium  iodide.  A  drachm  in  water  should  be  given 
every  six  hours.  In  some  cases  in  which  asthma  has  been 
contracted  in  malarious  climates,  or  in  which  a  neuralgic 
element  is  traceable,  quinine  may  be  usefully  given  in  com- 
bination with  iodide  of  potassium.  Five  grains  of  salicylate 
of  quinine  in  pill  (with  citric  acid)  may  be  taken  three  times  a 
day,  either  at  separate  times  or  with  each  dose  of  iodide. 

In  hay  asthma  the  use  of  pollantin,  the  specific  serum  pro- 
duced under  the  direction  of  Professor  Dunbar®'^'  (see  p.  248), 
has  been  found  of  some  value.  The  dry  powdered  serum  should 
be  sniffed  up  into  the  nose  on  first  waking  in  the  morning,  and 
again  several  times  during  the  day,  whenever  the  slightest 
sign  of  an  attack  appears.  The  pollantin,  whether  in  the  dry 
or  liquid  form,  should  also  be  applied  to  the  eye  if  necessary. 
General  precautions,  such  as  sleeping  with  the  windows  closed 
during  the  hay-fever  season,  should  not  be  omitted.  In  cer- 
tain cases  the  results  to  the  hay  fever  and  the  hay  asthma  from 
this  specific  treatment  have  been  gratifying,  the  patient  having 
been,  for  a  time  at  least,  freed  from  his  complaint.  In  other 
instances  failure  has  resulted,  or  some  amelioration  only 
obtained. 

Should  the  patient  come  under  observation  during  the  winter 
or  spring,  a  course  of  preventive  subcutaneous  inoculation 
with  "  Pollacine  "  (a  liquid  extract  containing  the  pollen  pro- 
tein) may  be  tried,*  it  having  been  first  shown  by  a  positive 
ophthalmic  reaction  that  the  patient  is  a  sufferer  from  true 
hay  fever.  In  certain  cases  considerable  relief  is  thus  given 
during  the  succeeding  summer. 

Relief  from  the  itching  of  the  eyes  and  the  sneezing  which 
are  so  often  associated  with  hay  asthma  may  be  obtained  by 
inhaling  from  a  handkerchief  a  solution  containing  camphor 
3ss.,  menthol  3i.,  paroleine  si.,  or  by  lightly  plugging  the 
anterior  nares  with  cotton-wool  moistened  with  a  solution  of 
four  grains  of  hydrochloride  of  cocaine  in  one  ounce  of  a 
I  in  10,000  solution  of  adrenalin  hydrochloride.      The  plug 

*  Outfits,    prepared    in    the    Inoculation     Department    of     St.     Mary's 
Hospital,  are  supplied  by  Mp.«;srs.  Parke,  Davis  and  Co. 


ASTHMA  263 

should  be  inserted  in  the  early  morning  on  rising,  and  again 
during  the  day,  whenever  the  earhest  signs  of  an  attack  are 
noticed.  If  any  highly  sensitive  spots  be  discoverable  in 
the  nasal  mucous  membrane,  they  may  be  cauterised.  Atten- 
tion must  be  paid  to  the  digestion  and  the  general  health, 
and  in  some  cases  a  sea  voyage  may  be  prescribed  v^^ith  advan- 
tage, or  a  short  residence  at  one  of  our  seacoast  places,  such 
as  Yarmouth  or  other  exposed  marine  station. 

Alcoholic  stimulant  should  only  be  given  in  asthma  when 
necessary  as  a  restorative  and  in  small  doses.  Strong  coffee 
is  of  great  value  as  a  restorative  after  a  severe  paroxysm,  and, 
as  we  have  seen,  in  some  cases  it  distinctly  relieves  spasm. 
Caffeine  (two  or  three  pills  of  2J  grains  each,  made  with 
glycerine  of  tragacanth)  may  be  taken  for  the  same  purpose. 
After  an  attack  of  asthma,  especially  if  it  has  been  severe 
and  has  left  any  pulmonary  oedema  behind,  it  is  a  good  prac- 
tice to  give  small  doses  of  digitalis  (five  to  ten  minims  three 
times  a  day)  to  restore  tone  to  the  heart  and  small  vessels.  At 
this  period  arsenic  is  a  most  valuable  nerve  tonic. 

The  digestive  system  now  requires  careful  attention,  since 
the  secretions  will  necessarily  have  become  disordered  by  the 
drugs  used  for  the  relief  of  the  paroxysms,  and  by  the  venous 
congestion  of  viscera  attendant  upon  the  impeded  pulmonary 
circulation.  It  is  probable,  too,  that  the  function  of  the  pneu- 
m.ogastric  nerve  becomes  seriously  enfeebled  for  a  time  by  the 
attack  and  the  remedies  employed.  Some  pepsin  and  hydro- 
chloric acid  after  food,  in  combination  with  nux  vomica  or 
quinine,  given  an  hour  or  two  before  food,  will,  prove  service- 
able. The  most  careful  consideration  must  immediately  be 
given,  however,  as  to  whether  the  patient  can  be  moved  to  a 
more  suitable  locality,  and  this  may  in  some  cases  be  wisely 
effected,  even  in  the  midst  of  an  attack. 

The  Use  of  Vaccines  as  a  Prophylactic  Measure. — In  some 
cases  of  asthma  of  a  distinctly  catarrhal  type,  which  begin 
with  "  colds,"  influenza  attacks,  and  the  Hke,  and  cases  in  which 
there  is  chronic  bronchial  catarrh  with  asthmatic  paroxysms, 
the  use  of  an  appropriate  vaccine  is  attended  with  decided 
benefit.  The  vaccine  should  be  carefully  prepared  from  the 
sputum  of  the  subject,  the  M.  catarrhaHs  being-  in  many  cases 
the  principal  organism,  associated  perhaps  with  the  staphylo- 
coccus,   streptococcus,   pneumococcus,    or   Pfeiffer's   bacillus. 


264  DISEASES   OF   THE   LUNGS   AND   PLEURA 

The  vaccine  is  given  at  first  in  moderate  doses  twice  a  week, 
and  gradually  increased  according  to  the  degree  of  reaction, 
the  larger  doses  being  prescribed  at  first  once  a  week  or 
ten  days  and  then  once  a  month.  The  treatment  requires  to 
be  continued  for  several  months,  and  perhaps  renewed  from 
time  to  time,  selecting  a  few  weeks  precedent  to  the  times 
at  which  the  patient  is  most  Hable  to  his  attacks.  It  is  impor- 
tant to  remember  that  in  the  use  of  these,  as  indeed  of  all 
vaccines,  a  period  of  quietude  of  several  hours  should  succeed 
each  injection.  It  is  thus  convenient  to  give  the  injection 
about  teatime,  and  to  enjoin  that  the  patient  remains  in  bed 
until  noon  of  the  following  day,  by  which  time  the  degree  of 
reaction,  if  any,  will  have  been  noted. 

We  have  already  enjoined  great  caution  in  the  use  of  sera 
therapeutically  in  asthmatic  subjects,  whom  it  is  well  first  to 
desensitise  (see  p.  319). 

We  may,  perhaps,  conclude  this  chapter  with  an  account  of 
the  two  following-  cases.  The  first  is  an  example  of  bronchitis 
and  asthma  produced  by  the  inhalation  of  rosewood  dust,  in 
which  the  effect  of  treatment  was  very  striking. 

William  C ,  aged  thirty-eight,  residing  in  London,  was  a  man 

of  temperate  habits,  married,  witli  one  child  living ;  his  wife  had  had 
one  miscarriage,  but  there  was  no  history  of  syphilis.  He  had  been 
for  twenty  years  employed  as  a  fret-cutter.  Four  years  previous  to 
admission  into  the  Brompton  Hospital  he  had  had  an  attack  of 
bronchitis,  and  since  that  time  he  had  suffered  constantly  from  cough, 
with  suffocative  attacks  nearly  every  night.  Patient  had  never  had 
haemoptysis,  but  had  lost  flesh  considerably.  His  father  died  of 
rheumatic  gout,  and  his  mother  of  dropsy.  There  was  no  phthisis 
in  the  family.  On  admission  patient  complained  of  cough,  which 
became  worse,  and  was  attended  with  severe  attacks  of  dyspnoea  at 
night.  Expectoration  moderate ;  occasional  night-sweats ;  appetite 
poor ;  bowels  constipated. 

He  was  a  tall  and  fairly  well-built  man,  with  a  somewhat  suffused 
countenance  and  breathless  look.  The  chest  was  well  formed,  but 
expansion  with  inspiration  was  impaired.  The  percussion  note  over 
the  front  of  the  chest  was  hyper-resonant,  the  resonance  extending 
on  the  right  side  a  hand's-breadth  below  the  nipple,  on  the  left  side 
over  the  normal  area  of  heart's  dulness,  and  inferiorly  to  the  costal 
margin.  Diffused  sibilant  rales  were  audible  front  and  back,  and 
at  the  posterior  bases  some  mucous  rales  were  heard.  When  seen 
on  January  26  the  patient  had  been  in  hospital  three  days,  and  was 


ASTHMA  265 

suffering,  as  before  admission,  from  nightly  attacks  of  dyspnoea  and 
from  troublesome  cough.  He  was  on  the  ordinary  full  diet -of  the 
hospital.  The  "  Mistura  Potassii  lodidi  cum  Stramonio  "  of  the  hos- 
pital Pharmacopoeia,  containing  three  grains  of  iodide  of  potassium, 
J  grain  of  extract  of  stramonium  to  each  dose,  was  now  ordered  to  be 
taken  at  12  noon,  4  p.m.,  8  p.m.,  and  12  midnight,  the  diet  remaining 
the  same,  and  from  the  next  night  he  had  no  serious  dyspnoea.  On 
January  31  a  note  is  entered  :  "  Patient  feels  much  better,  and 
dyspnoea  almost  gone.  Cough  easier."  February  3  :  "  Has  not  felt 
suffocating  sensation  for  the  last  six  nights."  He  continued  the 
mixture,  however,  for  a  month,  and  then  took  it  in  half  doses  for 
another  fortnight.  On  February  8  respirations  were  free  and  un- 
accompanied by  rale,  and  by  the  end  of  the  month  the  cough  had 
disappeared.  On  leaving  the  hospital  at  the  beginning  of  March 
his  weight  was  9  stone  2  pounds,  an  increase  of  seven  pounds  since  his 
admission. 

It  should  be  observed  in  this  case,  as  in  many  others,  that  mere 
rest  from  his  dusty  occupation  did  not  sufifice  for  the  patient's 
recovery,  although  doubtless,  had  he  remained  in  pure  air  a  sufficient 
length  of  time,  he  might  have  recovered  without  treatment.  His 
attacks  had  the  paroxysmal  character  peculiar  to  asthma,  coming 
on  towards  the  small  hours  of  the  morning — i.e.,  after  a  certain  period 
of  repose — whilst  the  breathlessness  and  cough  of  the  bronchitis  and 
attendant  emphysema  were  constant  through  the  day.  Having 
regard  to  the  period  at  which  the  dyspnoea  became  distressing,  the 
stramonium  and  iodide  of  potassium  mixture  was  so  ordered  that  by 
midnight  he  had  taken  in  the  course  of  twelve  hours  a  grain  of 
stramonium  extract,  and  twelve  grains  of  the  iodide.  The  effect, 
as  we  have  seen,  was  striking  and  immediate. 

The  mechanism  of  the  dyspnoea  was  obvious.  The  man  had  an 
unduly  secreting,  and  probably  a  somewhat  thickened,  bronchial  tract, 
with  great  irritability  of  the  bronchial  muscular  apparatus,  and  con- 
stant tendency  to  spasm  of  the  tubes.  At  a  certain  time  after  repose 
secretion  would  accumulate  and  give  rise  to  spasm.  The  hypersensi- 
tiveness  upon  which  the  bronchial  spasm  depended  was  at  once  lessened 
by  the  stramonium,  whilst  the  iodide  had  a  more  permanently  altera- 
tive action  upon  the  mucous  membrane  and  its  secretion. 

The  patient  left  the  hospital  well,  but  after  a  time,  failing  to  find 
other  work,  was  reduced  to  the  necessity  of  recommencing  his  old 
employment,  and  soon  had  a  return  of  all  the  old  symptoms,  for  which 
he  was  treated  elsewhere  by  ordinary  remedies  (ether  and  expector- 
ants) without  avail.  We  have,  however,  since  seen  him  in  fairly 
good  health,  having  for  some  time  abandoned  his  former  work. 

In  the  trade  of  fret-cutting  the  operator  has  constantly  with  his 
mouth  to  blow  away  the  fine  wood-dust  that  collects  upon  his  work, 
and  thus  necessarily  inhales  much  of  the  dust.  The  patient  above 
referred  to  stated  that  he  could  distinguish  by  the  taste  the  different 
kinds  of  wood<  and  he  found  rosewood  (the  taste  of  which  he  com- 


266  DISEASES   OF   THE   LUNGS    AND   PLEURA 

pared  to  cayenne  pepper)  to  be  the  most  irritating.     Walnut-wood  was 
more  astringent  and  bitter,  but  less  irritating. 

Asthmatic  paroxysms  are  not  infrequently  associated  with 
bronchial  catarrh,  and  the  following  is  the  epitome  of  a  case 
in  which  a  chronic  bronchial  catarrh  of  gouty  incidence,  with 
heightened  blood-pressure  and  some  degree  of  arterio- 
sclerosis, was  so  associated,  the  special  feature  of  the  case 
being  the  constant  presence  in  the  sputum  of  numerous  casts 
varying  in  size  from  the  smallest  filaments  to  those  having 
a  diameter  of  J  inch  (Plate  XIV.). 

The  case  was  that  of  an  unmarried  lady,  aged  sixty-six,  seen  by 
Sir  Douglas  Powell,  in  consultation  with  Dr.  George  Smith  of  Henl^, 
in  July,  1919.  There  was  no  inheritance  of  an  asthmatic  kind,  and, 
although  for  many  years  subject  to  repeated  colds,  she  had  never  had 
an  attack  until  her  present  illness.  This  began  in  January,  1914,  with 
attacks  of  violent  sneezing,  which  recurred  every  few  days  without 
apparent  reason  and  were  not  influenced  by  remedies.  Between  the 
attacks  her  health  was  good.  The  spring  and  early  summer  months 
were  spent  on  the  Italian  Riviera,  at  Naples,  and  in  Rome  and 
Florence. 

Her  first  attack  of  asthma  occurred  at  Naples  late  in  the  spring,  and 
continued  in  Rome  and  Florence.  The  attacks  were  attended  with 
complete  obstruction  of  the  nasal  passages,  presumably  from  conges- 
tion of  the  mucous  membrane  covering  the  turbinate  bones,  and  with 
difficulty  in  speaking  or  swallowing  during  the  attacks.  Severe 
paroxysms  of  coughing  followed.  The  worst  attacks  occurred  between 
4  and  8  a.m.  ;  those  less  severe  between  4  and  8  p.m.  At  Florence  she 
was  laid  up  for  six  weeks  with  bronchitis,  and  on  convalescing  she  was 
passed  on  to  Ems,  where  she  had  a  relapse.  Finally  she  suffered  a 
terrible  ten  days'  journey  home  at  the  commencement  of  the  war. 
Vaccines  were  repeatedly  employed  on  the  Continent,  prepared  from 
the  sputum.  There  seems  to  have  been  some  uncertainty  as  to  the 
nature  of  the  microbe,  and  no  relief  was  derived  from  the  vaccines. 
From  1914  the  ashmatic  paroxysms  became  increasingly  frequent, 
and  the  only  remedy  that  gave  relief  was  adrenalin,  5  minims  sub- 
cutaneously  of  i  in  1,000  solution.  She  had  been  accustomed  to 
take  this  four  or  five  times  daily  for  relief  of  the  paroxysms.  In  May, 
1919,  she  underwent  an  operation,  quite  unconnected  with  the  air 
passages,  and,  as  is  so  common  in  asthma,  her  dyspnoeic  troubles 
entirely  cleared  away  for  seven  weeks  ! 

During  the  three  weeks  previous  to  the  consultation  in  July  the 
symptoms  had  been  gradually  returning,  and  in  the  past  fortnight  there 
had  been  several  hours  of  violent  sneezing  with  nasal  obstruction  and 
with  threatenings  of  the  bronchial,  asthma — symptoms,  in  fact, 
identical  with  those  with  which  her  illness  commenced  in  19 14. 


PLATE   XIV 


CASTS   FROM   THE   BRONCHIOLES   FROM   A   CASE   OF 
BRONCHITIC   ASTHMA 

The  drawing  shows  in  their  actual  size  numerous  small  bronchial 
casts  of  the  thickness  of  thin  string  or  cotton,  white  and  forkedi 
forming  collections  like  bunches  of  thin  white  ribbon.  They  were 
expectorated  by  a  lady,  aged  66,  of  gouty  diathesis,  who  suffered 
from  asthma  associated  with  bronchial  catarrh  and  raised  blood- 
pressure.     The  case  is  described  in  the  text  (p.  266). 


PLATE  XIV 


Casts  from  the  Bronxhioles  from  a  Case  of  Bfonchitjc  Asthma. 


To  face  p.  266. 


ASTHMA  267 

At  the  time  of  the  consultation  the  expectoration  was  considerable  in 
quantity,  mucoid  and  frothy,  and  containing  numerous  tangled  strings 
or  casts,  which  in  the  earlier  part  of  her  illness  were  sometimes  "  as 
thick  as  pencils,"  but  were  now  mostly  small,  quite  white,  forked,  and 
of  the  thickness  of  thin  string  or  cotton,  forming  collections  rather 
like  bunches  of  little  white  ribbons.  Fearing  she  might  have  a 
spasm  during  examination,  the  lady  had  taken  5  minims  of  adrenalin 
twenty  minutes  previously.  The  breathing  was  quiet,  and  there  was  no 
cough  during  the  interview ;  the  pulse  84,  of  notably  high  tension,  the 
blood-pressure  being  found  to  be  95  diastolic  and  205  systolic.  The 
heart's  apex  beat  was  slightly  to  the  left  of  the  normal,  the  sounds 
clear,  and  the  second  sound  heavy  and  accentuated.  There  was  some 
slight  sclerosis  of  the  vessels.  The  lungs  were  a  little  emphysematous, 
and  over  the  bases  posteriorly  fine  crepitating  rales  were  heard,  which 
diminished,  but  did  not  disappear,  after  several  deep  inspirations. 

The  finger-ends  were  enlarged  with  gouty  arthritis,  and  it  was 
elicited  that  the  lady  had  always  been  gouty  and  had  had  several 
distinct  attacks  of  gout  in  the  feet. 

Dr.  Smith  subsequently  made  several  examinations  of  the  blood- 
pressure  apart  from  adrenalin  influence,  and  found  the  average  pres- 
sure about  165 ;  sometimes  over  180 ;  once  as  low  as  140. 

The  patient  had  lately  been  living  in  rooms,  with  stuffy  furniture 
and  insufficient  air,  and  a  removal  to  Peppard  Common,  with  wheel- 
chair and  quiet  exercise,  together  with  iodine  and  eliminative  treat- 
ment, proved  beneficial.  On  her  return  home,  however,  although  con- 
tinuing the  better  hygienic  conditions,  the  symptoms  relapsed,  but 
with  less  severity.  The  drawing  in  Plate  XIV.  was  taken  from  a 
specimen  of  sputum  expectorated  in  January,  1920.  The  report  stated 
that  "  the  sputum  consists  of  mucus  in  which  are  whitish  strings  of 
varying  size.  These  consist  of  mucoid  material,  with  a  tough, 
tenacious,  possibly  fibrinous,  core,  in  which  are  a  few  bronchial  cells 
and  abundant  leucocytes,  but  no  alveolar  cells.  The  prevailing 
organism  seen  in  a  stained  film  was  a  Gram-negative  bacillus  of 
coliform  appearance,  but  there  were  also  a  very  few  cocci." 

The  case  was  complicated  with  epithelioma  quite  unconnected  with 
the  pulmonary  organs.  During  the  last  few  weeks  of  her  life,  appar- 
ently under  the  influence  of  salicylate  of  soda,  the  patient  was  again 
relieved  of  all  asthmatic  symptoms.  It  must,  however,  be  recorded 
that  during  this  time  she  had  several  smart  haemorrhages  from  the 
malignant  growth,  in  one  of  which  she  died  in  the  spring  of  1920. 
There  was,  as  shown  on  two  examinations,  no  marked  association 
with  bacterial  organisms,  and  consequently,  as  one  might  expect, 
vaccines  proved  of  no  avail. 


REFERENCES. 

{a)  On  Asthma:  its  Pathology  and  Treatment,  by  Henry  Hyde  Salter. 

M.D.,  F.R.S.,  London,  1868. 
[b)  Loc.  cit.,  p.  46. 


268  DISEASES   OF   THE  LUNGS   AND   PLEURA 

^  (a)  Article  on  "Angina  Pectoris,"  by  Sir  R.   Douglas  Powell,   Bart., 
K.C.V.O.,     M.D.,     F.R.C.P.,    Allbutt    and    Rolleston's    Sysiem    of 
Medicine,  vol.  vi.,  p.   170.     London,   1909. 
{b)  Loc.  cit.,  p.  166  (Case  3 — Mrs.  F.). 
^  "  Report   of    Experiments   on   the   Physiology  of   the  Lungs   and  Air- 
tubes,"   by   Charles  J.   B.   V\fiUiams,    M.D.,   F.R.S.,   Report  of  the   Tenth 
Meeting  of  the  British  Associatiojt  for  the  Advancement  of  Science,  p.  411. 
London,  1841. 

*  (i)   "  Contributions  to  the  Physiology  of  the  Lungs  "   (part  i.),  "The 

Bronchial  Muscles  :  Their  Innervation  and  the  Action  of  Drugs 
upon  Them,"  by  W.  E.  Dixon,  M.D.,  and  T.  G.  Brodie,  M.D., 
Journal  of  Physiology,  1903,  vol.  xxix.,  p.  97. 
(2)  "  The  Pathology  of  Asthma,"  by  T.  G.  Brodie  and  W.  E.  Dixon, 
Transactions  of  the  Pathological  Society  of  Lotidon,  1903,  vol.  liv., 
p.  17. 

*  "  On  the  Probable  Rhythmic  Contraction  of  the  Bronchial  Muscular 
Coat  as  a  Factor  in  Pulmonary  Diseases,"  by  P.  Watson  Williams,  M.D. 
(Lond.),  Bristol  Med.  Chir.  Journal,  vol.  xxi.,  1903,  p.  6. 

^  "  Toxic  Idiopathies,"  by  John  Freeman,  M.D.,  British  Medical 
Journal,   1920,   vol.    i.,   p.   403. 

'  (fl)  "A  Clinical  Study  of  400  Patients  with  Bronchial  Asthma,"  by 
I.  Chandler  Walker,  M.D.,  Boston  Medical  and  Surgical  Journal, 
1918,  vol.  clxxix.,  p.  2S8. 
{b)  "  The  Treatment  of  Bronchial  Asthma  with  Proteins "  (with 
bibliography),  by  I.  Chandler  Walker,  M.D.,  The  Archives  of 
Internal  Medicine,   vol.   xxii.,    1918,   p.   466. 

'  "  Untoward  Results  from  Diphtheria  Antitoxin,  with  Special  Refer- 
ence to  its  Relation  to  Asthma,"  by  H.  F.  Gillette,  M.D.,  Therapeutic 
Gazette,  1909,  p.   159. 

°  (i)  See  "  Zur  Serumbehandlung  des  Heufiebers,"  von  Dr.  A.  Liibbert 
Therafeutische  Monatshefte,  December,  1904,  p.  605. 
■  2)  "  Hay  Fever  :   Recent  Investigations  on  its  Cause,  Prevention  and 
Treatment,"  by  R.  Ashleigh  Glegg,  M.B.,  Journal  of  Hygiene,  1904, 
vol.  iv.,  p.  369. 

10  ti  Tucker  v.  Wakley  and  Another,"  evidence  by  Dr.  William  Henry 
Willcox,  The  Lancet,  1908,  vol.  i.,  p.  338. 


CHAPTER  XVI 

PULMONARY  VESICULAR  EMPHYSEMA 

Pulmonary  vesicular  emphysema  may  be  defined  as  a  dilata- 
tion of  the  air-cells  and  infundibula  of  the  lungs,  with  antece- 
dent or  associated  atrophic  changes,  or,  more  briefly  still,  as  a 
dilatation  of  the  lung  proper  with  textural  atrophy. 

In  its  acute  form  this  disease  may  affect  persons  of  any  age, 
but  is  especially  apt  to  occur  in  children  as  a  complication  of 
whooping-cough  or  capillary  bronchitis.  In  its  chronic  and 
more  permanent  form  it  affects  most  commonly  persons  in 
middle  or  advanced  middle  Hfe.  Atrophic  or  senile  emphysema, 
which  scarcely  merits  consideration  as  a  variety  of  the  disease, 
affects  only  aged  people,  and  is,  indeed,  but  a  part  of  the  senile 
state. 

Pathology. — The  perfectness  of  the  function  of  respiration 
consists  quite  as  much  in  the  power  of  contracting  as  in  that  of 
filling  the  chest,  and  it  is  this  power  of  contracting  the  chest 
that  is  lost  in  emphysema.  The  lungs,  having  lost  their 
reserve  elasticity,  no  longer  tend  further  to  contract  at  the 
completion  of  expiration;  nay,  expiration  is  never  completed; 
the  thoracic  parieties  and  diaphragm,  instead  of  being  drawn 
inwards  by  the  traction  of  the  lungs,  recoil  simply  to  their 
position  of  repose,  and  oppose  their  dead  weight  to  the  in- 
spiratory muscles  instead  of  aiding  the  action  of  these  muscles 
by  their  elastic  rebound.  Hence,  in  extreme  emphysema  the 
inspiratory  act,  commencing  at  the  point  where  in  health  calm 
inspiration  would  end,  has  to  overcome  (i)  what  remains  of 
the  elastic  resistance  of  the  lungs ;  (2)  the  inertia  and  the 
resistance  of  the  parietes,  instead  of,  as  in  health,  having  to 
deal  with  the  elastic  resistance  of  the  lungs  alone,  and  being 
in  this  work  aided  by  the  outward  spring  of  the  ribs  (see  p.  9). 
Consequently,  in  marked  cases  the  breathing  is  always  forced, 
and  more  or  less  difficult. 

269 


2/0  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Let  us  now  briefly  recount  the  conditions  present  in  emphy- 
sema, making  such  additional  comments  as  seem  called  for. 

1.  The  lungs  in  all  cases  of  decided  emphysema  are  per- 
manently expanded  to  about  the  position  of  ordinary  inspira- 
tion, their  elasticity  being,  so  to  speak,  relaxed  to  this  point. 
The  enlargement  commences,  as  pointed  out  by  Rindfleisch,"^ 
in  the  infundibula,  and,  according  to  Dr.  Arthur  Keith,^  affects 
this  portion  of  the  lung  chiefly.  As  a  result  of  these  changes, 
the  pulmonary  vascular  system  becomes  lengthened.  In  acute 
emphysema  loss  of  tone  from  repeated  over-distension,  e.g., 
during  paroxysms  of  coughing,  is  the  chief  defect  present, 
and,  in  young  persons  especially,  is  speedily  recovered 
from. 

2.  The  texture  of  the  lung  is  to  a  greater  or  less  extent 
impaired. 

In  cases  of  long-standing  emphysema  resulting  from  re- 
peated attacks  of  asthma  or  bronchitis,  what  may  be  regarded 
as  the  second  stage  of  the  disease  is  entered  upon;  and  the 
lung  suffers  in  nutrition  and  elasticity.  Many  of  the  small 
bloodvessels  become  obliterated,  withering  backwards  from 
their  capillaries,  a  result  due  in  part  to  primary  degenerative 
changes  in  the  capillaries,  and  in  part  to  atrophic  changes 
consequent  upon  the  narrowing  and  stretching  to  which  the 
vessels  are  subjected  as  the  lung  enlarges.  Concurrently  with 
these  changes  the  alveoli  atrophy,  the  portions  between 
adjacent  infundibula  or  alveolar  spaces  become  thinned  and 
finally  give  way,  and  the  spaces  here  and  there  coalesce  to 
form  blebs  or  small  cavitations,  with  thread-like  remnants  of 
vessels  crossing'  them,  resembling  in  miniature  the  trabeculse 
of  tuberculous  cavities.  Where  the  disease  has  resulted  from 
oft-recurrent  catarrhs,  commonly  with  a  history  of  a  distinct 
attack  of  bronchitis  at  the  commencement,  ill-developed 
fibrous  tissue,  the  result  of  repeated  and  long-continued  con- 
gestion and  nuclear  proliferation  in  the  submucous  layer, 
toughens  the  lung  texture,  assists  in  impairing  elasticity,  and 
partakes  in  the  subsequent  degeneration.  Similar  changes 
occur  in  the  local  emphysema  developed  about  old  tuberculous 
centres  in  the  lung. 

In  cases  of  constitutional  or  hereditary  origin  the  atrophic 
changes,  whether  originating  in  fatty  degeneration  of  the 
pulmonary  epithelium,  or  of  that  of  the  vessels  of  the  lungs. 


PULMONARY    VESICULAR   EMPHYSEMA  27 1 

or  in  a  primary  degeneration  and  rupture  of  the  elastic  fibres 
— and  on  these  points  authorities  are  by  no  means  agreed'' — 
would  appear  to  precede  or  accompany  the  catarrhal  phe- 
nomena. This  impairment  of  the  texture  of  the  lung  renders 
any  dilatation,  however  induced,  more  or  less  permanent.  In 
these  cases  of  primarily  impaired  lung-  texture,  enlargement 
of  the  chest  to  the  limits  of  thoracic  resilience  takes  place 
quite  insidiously,  and  the  chest  thus  assumes  permanently,  by 
imperceptible  degrees,  the  position  of  moderate  inspiration. 
It  must  not  be  forgotten,  too,  that  the  ribs  themselves,  and 
especially  their  cartilages,  often  prematurely  undergo  textural 
changes  of  a  degenerative  kind,  the  result  of  which  is  an 
increased  rigidity  and  a  straightening  of  the  rib  arch,  and  so 
an  enlargement  of  the  thorax. 

3.  In  consequence  of  the  relaxed  elasticity  of  the  enlarged 
lungs,  they  no  longer  exercise  any  traction  upon  the  medias- 
tinum except  during  inspiration.  Hence  an  important, 
because  constant,  aid  to  the  return  of  blood  to  the  heart  is 
lost. 

Many  authors  go  farther  than  this,  and  hold  that  the  large 
lungs  in  emphysema  are,  so  to  speak,  pent  up  in  the  chest,  and 
exercise  pressure  upon  the  heart  which  lies  between  them, 
and  upon  the  ribs  and  diaphragm  which  enclose  them.  A 
little  reflection  and  clinical  observation  will,  however,  render 
it  clear  that  this  supposed  pressure  of  the  lungs  upon  the 
surrounding  parts  is,  if  not  impossible,  of  infinitely  rare 
occurrence  and  minute  in  degree.  The  enlarged  thorax, 
flattened  diaphragm,  and  lowered  heart,  are  all  phenomena 
due  to  defective  recoil  of  the  lungs,  not  to  their  active  disten- 
sion, and  are  to  be  observed  in  health  on  the  lungs  being 
inflated  during  deep  inspiration,  a  position  which  is  retained 
in  emphysema. 

4.  In  addition  to  the  negative  impediment  to  the  circulation 
referred  to  in  the  preceding  proposition,  there  is  a  positive 
impediment  in  the  stretched,  and  in  part  obliterated,  capillaries 
of  the  lungs. 

5.  In  consequence  of  the  two  last-mentioned  conditions,  the 
venous  system  is  overfull,  and  the  overworked  right  heart 
thickens.  The  increased  power  of  the  right  ventricle  at  length 
becomes,  however,  inadequate  to  contend  against  the  ever- 
present  resistance  to  the  pulmonary  circulation,  a  resistance 


2/2  DISEASES   OF  THE  LUNGS   AND   PLEUR.E 

which  is  from  time  to  time  accentuated  during  attacks  of 
bronchitis  or  asthma,  and  the  whole  venous  system  becomes 
engorged.  With  general  venous  congestion  the  return  of 
blood  from  the  coronary  veins  is  impeded,  and  the  heart 
muscle  suffers  in  nutrition,  undergoing  fibroid  degeneration. 
This  in  its  turn  leads  to  imperfect  contraction  of  the  ventricles, 
and  causes  them  to  yield  gradually  before  the  heightened 
blood-pressure.  Hence  follows  a  greater  degree  of  venous 
stagnation  and  engorgement,  especially  in  the  hepatic  and 
portal  systems.  Venous  haemorrhages  tend  to  occur,  and 
oedema,  commencing  in  the  legs,  sooner  or  later  sets  in. 

6.  Another  effect  of  the  relaxed  state  of  the  lung  in  extreme 
emphysema  is  to  interfere  with  that  condition  of  permanent 
patency  in  which  the  small  bronchi  are  normally  held  by  the 
constant  traction  of  the  elastic  lung  upon  them  from  all  sides. 
In  emphysema  this  traction  becomes  neutralised  during'  ex- 
piration, and  in  more  advanced  cases  collapse  of  the  bronchioles 
must  then  occur,  thus  accounting  for  the  laboured  and 
obstructed  character  of  that  portion  of  the  respiratory  act. 

7.  Amongst  the  consequences  of  emphysema,  those  which 
are  of  the  nature  of  compensation  must  not  be  forgotten.  So 
ready  are  the  adaptations  of  our  economy  to  altered  circum- 
stances, that  it  may  be  said  that  emphysema  alone  does  not 
kill,  (a)  As  the  capillaries  become  partially  obliterated,  fresh 
communications  are  opened  up  with  the  neighbouring  vessels 
corresponding  to  them  by  the  formation  of  anastomotic  loops, 
or  by  the  widening  of  communications  already  existing. 
The  pulmonary  and  systemic  veins,  we  may  remember,  com- 
municate normally  on  the  walls  of  the  smaller  bronchi,  and 
with  the  formation  of  pleuritic  adhesions,  so  common  in  this 
disease,  loops  of  new  vessels  connect  the  pulmonary  with  the 
systemic  circulation;  and  especially  along  the  insertion  of  the 
diaphragm  and  margins  of  the  sternum,  fringes  of  enlarged 
vessels  mark  the  connection  between  the  two  circulations. 
Thus,  in  some  measure  the  pressure  of  the  pulmonary  circula- 
tion is  eased,  (b)  The  hypertrophy  of  the  right  ventricle  of 
the  heart  above  alluded  to  is,  up  to  a  certain  point,  of  a  strictly 
compensatory  nature,  serving  to  overcome  by  augmented 
power  the  increasing  impediment  to  the  pulmonary  circula- 
tion. Thus,  for  a  time  at  least,  equihbrium  is  maintained,  to 
be    disbalanced    again   and   again,   however,   by   intercurrent 


PULMONARY   VESICULAR   EMPHYSEMA  273 

attacks  of  bronchitis  or  other  cause  of  overstrain,  until  at 
last  the  limits  of  compensatory  recuperation  are  passed. 

Etiology. — When  we  come  to  inquire  how  this  over-expan- 
sion of  the  air-vesicles  is  produced,  we  are  met  by  various 
explanations,  no  one  of  which  alone  is  sufficient  to  account 
for  all  cases.  Sir  William  Jenner*  demonstrated  that  ex- 
piratory effort  during  straining"  or  coughing,  particularly  the 
latter,  is  an  efficient  cause  of  general  emphysema,  those 
portions  of  lung  which  are  least  supported,  viz.,  the  apices  and 
anterior  margins,  and  also  the  parts  corresponding  with  the 
comparatively  yielding  intercostal  spaces,  becoming-  first 
affected.  But  with  the  production  of  emphysema  in  these 
portions  of  the  lungs,  a  shifting  of  the  relationship  between 
the  lung  and  the  thoracic  surface  takes  place,  and  parts  which 
were  originally  in  apposition  with  the  ribs  come  to  be  opposed 
to  interspaces,  and  in  their  tutn  yield  before  the  distending 
force  of  air  pent  up  and  compressed  during  cough.^' 

Following  this  view,  it  has  been  believed  that  the  playing 
upon  wind-instruments  is  an  occupation  likely  to  lead  to 
emphysema  from  the  expiratory  efforts  involved.  The  ex- 
perience at  the  Foundling  Hospital  would,  however,  suggest 
that  in  young  and  healthy  subjects  this  is  not  the  case. 
At  this  institution  many  of  the  boys  are  trained  for  the 
regimental  bands,  and  Dr.  J.  C.  Swift,  for  many  years  Medical 
Officer  to  the  hospital,  informs  us  that  over  a  period  of  more 
than  twenty  years  only  one  case  of  emphysema  developed 
among  nearly  600  boys  so  trained.  The  subsequent  health 
also  of  these  boys  in  the  army  has  been  good. 

Other  authorities,  commencing  with  Laennec,^  have  held 
that  inspiratory  pressure  is  the  chief  factor,  and  in  the  pro- 
duction of  local  emphysema  it  is  undoubtedly  an  important 
agent.  Thus,  if  one  lung  be  disabled  or  bound  down  by  some 
inflammatory  process  (as  old  pleurisy  or  chronic  pneumonia), 
the  other  lung  perforce  becomes  more  capacious;  whether 
this  extra  capacity  shall  be  derived  from  true  hypertrophy  or 
mere  dilatation  (emphysema)  depends  upon  the  nutritive 
vigour  of  the  patient.     During  bronchitis  certain  of  the  air- 

*  Sir  William  Jenner  (Reynolds's  System  of  Medicine,  vol.  iii.,  p.  478) 
refers  to  Mendelssohn  as  having  in  a  paper,  "  Der  Mechanismus  der 
Respiration  und  Circulation,"  in  1845,  anticipated  him  in  his  view  re- 
specting emphysema.  The  authorship  and  advocacy  of  the  view  in  this 
country  rests,  however,  with  Sir  W.  Jenner. 

18 


274  DISEASES   OF  THE   LUNGS   AND   PLEURA 

tubes  may  become  occluded  by  mucus,  and  the  inspiratory 
force  then  operates  as  a  distending  power  upon  the  remaining 
portions  of  the  lung  until  the  deficiency  in  air-space  is  com- 
pensated. Thus,  in  the  words  of  Rindfleisch,^*  who  adopted 
the  late  Sir  William  Gairdner's"  inspiratory  theory  in  regard 
to  the  production  of  emphysema,  "during  the  antecedent 
bronchitis,  first  one,  then  another  bronchial  tube  is  plugged 
with  secretion,  and  so  first  one,  then  another  segment  of  the 
lung  is  subjected  to  an  abnormal  degree  of  [inspiratory]  dis- 
tension," until  at  length  general  emphysema  is  produced. 
Dr.  Gee,''  in  his  Lumleian  Lectures,  also  advocated  the  in- 
spiratory as  being  the  chief  factor  in  the  production  of 
emphysema. 

An  impartial  view  of  the  matter  renders  it  clear  to  us  that 
each  of  these  theories  is  valid  and  applicable  to  a  considerable 
number  of  cases,  now  one  and  now  the  other  predominat- 
ing. But  both  inspiratory  and  expiratory  theories  imply  the 
presence  of  some  pre-existing  bronchitis,  or  some  local  lesion 
disabling  a  portion  of  the  lung,  conditions  which  are  wanting 
in  a  considerable  proportion  of  cases. 

In  truth,  the  emphysema  frequently  precedes  the  bronchial 
affection,  although  it  is  subsequently  aggravated  by  the 
attacks  of  bronchitis;  and  admitting  with  the  late  Dr.  Green- 
how^  and  others  that  a  failure  of  nutrition  is,  in  a  large  propor- 
tion of  cases,  the  predisposing  cause  of  emphysema,  we  need 
go  but  little  farther  to  explain  the  occurrence  of  that  disease 
in  its  earlier  grades.  The  effect  of  damaged  nutrition  of  the 
lungs  is  to  impair  their  elasticity  and  traction  upon  the 
thoracic  walls.  As  we  have  elsewhere  shown  (see  p.  ii),  the 
thoracic  resilience  tends  to  expand  the  chest  from  i  to  3 
millimetres  in  each  direction;  in  proportion,  therefore,  as  the 
lungs  lose  elasticity,  they  yield  to  this  resilience  of  the  thoracic 
wall,  and  to  the  weight  of  the  abdominal  organs  dragging  upon 
the  diaphragm,  and  thus  the  lung  is  expanded  to  such  a  degree 
that  any  further  extension  will  suffice  to  cause  symptoms  of 
dyspnoea.  Calcareous  degeneration  affecting  the  cartilages 
and  ribs,  referred  to  by  Freund,®  causing  loss  of  elasticity  of 
these  parts,  may  lead,  for  reasons  already  given,  to  a  rigid 
enlargement  of  the  chest  cavity.  This  change  takes  place 
pari  passu  wath,  or  may  even  precede,  the  loss  of  pulmonary 
elasticity,  and  thus  plays  a  part  in  the  aetiology  of  the  disease. 


PULMONARY   VESICULAR   EMPHYSEMA  275 

It  is  from  this  latter  view  of  its  mechanism  that  one  can 
appreciate  the  fact  that  in  emphysema  the  chief  defect  consists 
in  the  lessened  power  of  contracting  the  chest,  and  thereby 
emptying  the  lungs.  The  act  of  expiration  is  never  com- 
pleted; there  is  too  much  residual  air  constantly  in  the  lungs, 
and  inspiration  is  short  and  jerking,  the  act  commencing 
where  it  should  end. 

The  force  of  expiration,  as  estimated  by  the  manometer,  is 
remarkably  lessened  in  emphysema,  whilst  that  of  inspiration 
remains  normal,  or  may  even  be  increased  (Waldenburg),'° 
the  relationship  between  inspiration  and  expiration  being 
thus,  in  this  respect,  the  reverse  of  that  obtaining  in  health. 
The  vital  capacity  of  persons  with  emphysema  is,  as  might  be 
supposed,  greatly  curtailed. 

Varieties  of  Pulmonary  Vesicular  Emphysema. 

The  distribution  of  pulmonary  vesicular  emphysema  may 
be  local  or  general,  and,  as  above  shown,  it  may  vary  in  degree 
between  wide  limits. 

Local  Pulmonary  Vesicular  Emphysema. — This  may  be  met 
with  as  a  dilatation  of  the  lung,  accompanied  by  more  or  less 
atrophic  changes,  around  old  cicatrising  nodules  of  disease, 
contracting-  cavities,  or  points  of  pulmonary  collapse.  The 
site  of  the  emphysema  is  here  determined  by  that  of  the 
primary  lesion,  on  which  its  presence  mechanically  depends. 
Whilst  the  effect  of  the  emphysema  is  clinically  to  mask  the 
physical  signs  proper  to  the  consolidation,  it  brings  no  com- 
pensatory advantage  to  the  patient,  since  the  emphysematous 
portions  of  the  lung  are  deficient  in  respiratory  function. 

Again,  it  sometimes  happens  that  a  whole  lung  is  disabled 
by  destructive  disease,  by  permanent  collapse  from  long- 
continued  fluid  pressure  or  interstitial  fibrous  growth.  In 
these  cases  it  is  inevitable  that  the  opposite  and  originally 
unaffected  lung  shall  enlarge,  and  fortunately  in  many  in- 
stances this  enlargement  is  really  of  the  nature  of  compen- 
satory hypertrophy;  there  is,  that  is  to  say,  greatly  increased 
mobility  of  the  side,  the  respiratory  murmur  is  loud  and 
puerile  over  the  whole  extended  area  of  the  lung,  and  the 
patient's  breathing  powers  are  fairly  maintained.  We  may, 
therefore,  safely  assume  in  such  cases  increased  function 
corresponding  with  increased  size,  which  is  at  least  the  clinical 


2/6  DISEASES   OF   THE  LUNGS   AND   PLEUR/E 

definition  of  true  hypertrophy.  On  minute  examination  we 
believe  that  a  corresponding  development  of  lung  texture, 
with  increased  blood-supply,  and  an  absence  of  the  atrophic 
changes  of  emphysema,  would  be  found.^^ 

In  other  cases,  however,  in  which  the  lung  disablement  has 
occurred  in  a  subject  of  broken  constitution,  whether  from 
hereditary  tendency,  prolonged  fever,  faulty  habits,  or  com- 
paratively advanced  age  at  the  time  of  attack,  the  "  sound " 
lung,  whilst  enlarging  to  the  clinical  outline  and  pattern  of 
hypertrophy,  does  not  yield  to  auscultation  evidence  of 
vigorous  breathing,  but  a  feeble  diluted  breath-sound,  want- 
ing in  concentrated  vesicular  quality.  The  expanded  side 
lacks  mobility,  and  rustling  crepitant  sounds  may  be  heard 
at  different  points,  especially  near  its  anterior  margin.  The 
patient  has  not  the  signs  of  improved  aeration,  he  presents  a 
livid  tinge  about  the  peripheral  parts  and  extremities,  and  his 
enlarged  lung  has  brought  no  corresponding  relief  to  his 
breathless  condition.  Here  we  have  a  dilatation  of  the  lung 
mechanically  induced,  and  attended  with  atrophic  changes,  a 
condition  which  constitutes  emphysema. 

General  Pulmonary  Vesicular  Emphysema  —  i.  Large- 
Lunged  Emphysema.  —  This  is  the  condition  of  typical 
symmetrical  emphysema,  to  the  description  of  which  this 
chapter  is  chiefly  devoted.  It  is  only  necessary  further  to 
say,  or  rather  to  repeat,  that  there  are  really  two  groups  of 
cases  included  in  the  variety — viz.,  (i)  that  in  which  the  disease 
is  distinctly  secondary  to  recurrent  bronchitis  or  to  chronic 
lung"  overstrain,  and  in  which  the  degenerative  changes  super- 
vene, and  render  the  lesion  permanent;  (2)  that  in  which  the 
atrophic  changes  are  primary,  and  the  bronchitis  and  other 
phenomena  are  secondary.  The  latter  cases  are  either  hered- 
itary or  are  induced  by  intemperate  living,  gout,  syphilis,  or 
other  acquired  cachexia. 

2.  Small-Lunged  or  Senile  Emphysema. — This  resembles 
the  second  group  of  the  last  variety  in  being  an  emphysema  of 
essentially  atrophic  origin.  It  is,  however,  but  the  atrophy  of 
old  age  most  obvious  at  the  lungs,  but  present  everywhere. 
The  pathology  of  this  disease,  if  such  it  can  fairly  be  called, 
is  identical  with  that  of  the  preceding,  save  that  it  supervenes 
in  lungs  already  small  and  shrunken  with  the  general  atrophy 
of  the  body.     Persons  thus  affected  are  prone  to  bronchial 


PULMONARY    VESICULAR   EMPHYSEMA  277 

attacks,  and  their  heat-sustaining  powers  are  very  feeble ;  but 
under  good  conditions  of  warmth  and  clothing,  with  careful 
living,  and  a  moderate  amount  of  stimulants,  they  may  enjoy 
life  to  even  beyond  the  average  age. 

Symptomatology. — The  clinical  phenomena  presented  by 
cases  of  marked  emphysema  are  only  in  comparatively  small 
part  significant  of  the  emphysematous  lung,  being  largely  due 
to  attendant  and  for  the  most  part  secondary  lesions.  The 
physical  signs  will  be  sufficiently  indicated  in  the  description 
of  the  following  extreme  case  of  the  disease : 

George  D ,  oil  and  colour  warehouseman,  aged  about  fifty,  was 

admitted  into  the  Brompton  Hospital  under  the  care  of  Dr.  Douglas 
Powell.  The  patient  was  a  tall  man,  with  no  hereditary  tendency 
to  phthisis,  but  of  gouty  parentage  on  the  father's  side.  He  had  up 
to  three  years  before  admission  never  been  laid  up  with  any  illness. 
At  that  time  he  had  an  attack  of  bronchitis,  and  since  then  had 
complained  of  shortness  of  breath  and  cough,  constant  in  the  winter, 
attended  with  frothy  and  viscid  expectoration  and  with  a  sense  of 
constriction  below  the  ribs.  He  had  never  spat  blood  nor  suffered 
from  hectic,  but  had  lost  and  then  regained  flesh  rapidly. 

His  principal  symptoms  on  admission  were  great  shortness  and 
difficulty  of  breathing,  the  head  and  face  becoming  congested,  almost 
cyanosed  at  times,  during  attacks  of  dyspnoea  and  cough.  He  had 
no  pain,  but  the  sense  of  constriction  below  the  ribs,  already  men- 
tioned, was  marked.  His  appetite  was  bad,  digestion  tolerably  good, 
bowels  irregular,  sleep  fair. 

Physical  Signs. — Pulse  86.  Temperature  normal.  Great  oedema 
of  lower  extremities  and  scrotum.  Chest  greatly  expanded.  Res- 
piration slow  and  forced.  Respiratory  movements  mainly  thoracic, 
and  extraordinary  muscles  of  respiration  prominently  employed. 
Intercostal  spaces  above  the  nipple  level  slightly  depressed  during 
inspiration,  becoming  quite  level  with  the  ribs  on  expiration.  Below 
the  nipple  level  the  intercostals  were  greatly  depressed  during  in- 
spiration, becoming  level  with  the  ribs  or  even  slightly  puffed  out- 
wards during  expiration.  The  seventh  and  eighth  ribs  yielded 
inwards  with  inspiration.  The  heart's  impulse  was  most  per- 
ceptible at  left  costal  margin  at  the  level  of  the  tip  of  the  ensiform 
cartilage. 

Girth  of  chest  on  each  side  above  nipple  level,  18  inches ;  at  the 
level  of  base  of  ensiform  cartilage  on  the  right  side,  i8f  inches,  and 
on  the  left  side,  18^  inches,  with  |  inch  extreme  inspiratory  ex- 
pansion. The  whole  chest  was  resonant  down  to  the  margin  of 
the  ribs  both  in  front  and  behind.  At  the  posterior  bases  on  both 
sides  fine  bubbling  rales  were  heard,  principally  with  inspiration. 
Similar  rales  were  also  heard  over  the  lower  two-thirds  of  the  right 
and    left    fronts.      Apices    clear.      Cardiac    sounds    unattended    with 


2/8 


DISEASES    OF   THE   LUNGS   AND   PLEURA 


bruit.  Abdomen  somewhat  distended,  and  containing  a  small  quantity 
of  fluid.     Liver  depressed. 

The  subjoined  tracings  show  well  the  nature  of  the  respiratory 
movements  in  this  case.  They  were  taken  by  a  simple  apparatus, 
consisting  of  a  straight  rod  connected  by  a  flexible  joint  with  an 
expanded  button  to  apply  to  the  chest,  the  other  end  writing  upon 
a  horizontal  sphygmograph  plate  previously  smoked. 

Tracing  Fig.  27  represents  the  movement  of  the  sternum  at  the 
level  of  the  third  cartilage,  the  patient  sitting  in  a  chair,  with  his  back 


Fig.  2-]. — Tracing  of  Respiratory  Movements  in  Emphysema,  showing 
Total  Forward  Thrust  at  Third  Mid-Sternum. 


resting  against  a  flat  board.  It  is  equivalent  to  exaggerated  thoracic 
breathing,  although  the  patient  was  inspiring  in  the  degree  natural 
and  necessary  for  him.  Tracing  Fig.  28  was  taken  on  the  seventh 
rib  in  the  lateral  region  right  side,  and  shows  a  distinct  recession 
(c,  c,  c)  during  each  inspiration.  This  was,  perhaps,  due  to  the 
bases  of  the  lungs  being  in  some  measure  disabled  by  secretion,  but 
the  disablement  and  collection  of  secretion  were  undoubtedly  in 
greatest  measure  owing  to  the  inaction  of  the  diaphragm  in  consequence 
of  the  flattening  of  its  arch.     The  thoracic  movement  was  certainly 


Fig.  28. — Tracing  showing  Recession  in  Emphysema  [c,  c,  c)  during 
Inspiration,  Seventh  Rib,  Axillary  Line. 


somewhat  in  excess  in  this  case  from  the  same  cause,  but  in  most 
cases  of  emphysema  the  respiration  becomes  thoracic  rather  than 
abdominal. 

The  patient  died,  after  he  had  been  in  the  hospital  three  weeks, 
from  general  dropsy  and  cyanosis. 

The  post-mortem  examination  revealed  the  usual  phenomena  of 
large  dilated  heart,  with  right  side  most  affected,  the  tricuspid  orifice 
measuring  65  inches  in  circumference ;   large  emphysematous   lungs, 


PULMONARY    VESICULAR   EMPHYSEMA  279 

the  emphysema  most  marked  at  the  anterior  and  upper  parts  and 
in  the  right  lung,  together  with  oedema  and  slight  congestion  at  both 
bases.  The  bronchial  tubes  contained  a  frothy  thin  fluid,  but  there 
were  no  signs  of  active  bronchitis.  The  spleen  was  hardened,  the 
kidneys  mechanically  congested,  and  the  liver  enlarged  and  fatty. 

Treatment. — It  will  be  obvious  from  what  has  preceded 
that  the  treatment  of  emphysema  is  mainly  palliative,  consist- 
ing of  the  prevention  of  fresh  catarrhs,  asthma,  and  bron- 
chitis, the  avoidance  of  over-exertion  and  straining  occupa- 
tions, the  escape  from  dusty,  irritating  atmospheres,  and,  when 
possible,  the  timely  migration  to  more  genial  climates  during 
the  winter  or  early  spring  months. 

We  cannot  cure  the  disease,  but  we  may  by  judicious 
measures  arrest  textural  decay,  and  prevent  fresh  overstrain. 
Emphysema,  let  us  again  remark,  is  never  fatal,  within  the 
normal  period  of  human  life,  save  by  its  complications,  but  it 
is  the  factor  which  endangers  recovery  from  many  diseases. 

In  the  dietetic  treatment  we  must  so  far  restrict  ingoings  as 
to  adapt  the  resulting  products  to  (i)  the  needs  of  a  necessarily 
limited  muscular  activity  and  a  diminished  metabolism;  (2)  to 
a  somewhat  retarded  circulation  through  the  lungs,  the  result 
of  capillary  obliteration;  (3)  to  a  lessened  oxygenation  and  a 
corresponding  tendency  to  plethora  of  venous  blood. 

A  restricted,  well-assorted  dietary,  and  the  maintenance  in 
fair  activity  of  the  eliminatory  functions  of  the  skin,  kidneys, 
and  bowels,  will  fulfil  the  double  indication  of  avoiding  sur- 
charge of  the  economy  by  waste  materials  and  diminishing  the 
tendency  to  venous  plethora,  visceral  congestion  and  over- 
work of  heart. 

With  regard  to  the  treatment  of  emphysema  by  drugs,  there 
are  certain  clear  indications  to  be  followed. 

Measures  for  the  regulation  of  secretions  have  been  alluded 
to,  and  are  of  great  importance,  but  require  no  further  detailed 
description. 

Intercurrent  attacks  of  bronchitis  or  asthma  will  require 
appropriate  treatment,  but  except  at  such  times  one  should,  so 
to  speak,  forget  the  lungs  in  the  medicinal  treatment  of  this 
complaint.  Dyspnoea  is  not  always  to  be  regarded  as  an 
indication  for  ether  nor  a  bronchial  wheeze  for  squills.  We 
must  rather  have  careful  regard  to  the  general  condition  of 
the  patient,  and  especially  to  vessel  and  heart  tonicity.     Iron, 


28o  DISEASES    OF   THE   LUNGS   AND   PLEURA 

arsenic,  and  strychnia  are  the  best  general  tonics,  and  should 
be  given  in  small  doses  for  lengthened  periods,  say  for  a  month 
at  a  time,  with  intervals  of  rest  from  drugs.  The  arseniate  of 
iron  is  an  excellent  preparation  for  our  purpose,  e.g.,  in  -^  to 
J  gr.  doses,  with  ^  gr.  of  extract  of  nux  vomica  and  some 
pepsin,  twice  a  day  after  food.  A  little  aloes  may  be  added 
if  necessary,  or  an  occasional  morning  dose  of  aperient  waters 
advised,  with  more  rarely  a  mercurial,  with  the  view  of  main- 
taining equilibrium  in  the  portal  system.  Ten  drop  doses  of 
jtincture  of  perchloride  of  iron,  with  a  little  strychnia,  twice  a 
day,  will  often  prove  of  value  in  restoring  muscular  tone  to 
the  heart  and  to  the  bronchi,  after  any  fresh  attack  of  bron- 
chitis or  asthma  involving  renewed  strain  upon  the  right 
ventricle.  Occasionally  at  these  times  it  is  desirable  to  give 
digitalis  in  moderate  doses  for  a  few  weeks;  five  minims  three 
times  in  the  day  is  usually  quite  sufficient  for  the  purpose. 

In  the  advanced  stages  of  emphysema  and  its  concomitant 
affections,  when  the  limbs  become  dropsical,  the  abdomen  full, 
the  viscera  engorged,  and — what  is  the  key  to  the  whole  situa- 
tion— ^with  the  right  ventricle  fluttering  at  the  epigastrium,  the 
pulse  small,  irregular,  and  intermitting,  and  the  jugulars  dis- 
tended and  filling  from  below,  absolute  rest  in  bed,  the  free 
administration  of  digitalis,  with  diuretics  and  diffusible  stimu- 
lants, will  sometimes  still  serve  to  rescue  such  patients  from 
impending  death.  The  flow  of  urine  freely  returns,  the  pulse 
steadies,  and  the  dropsy  subsides  under  this  treatment. 
Albuminuria,  usually  more  or  less  present  under  these  condi- 
tions, is  no  contra-indication  to  the  use  of  blue  pill,  which, 
given  in  combination  with  squill  and  digitalis  for  three  or  four 
successive  nights,  will  frequently  give  a  start  in  the  direction 
of  improvement. 

The  heart  is  the  failing  link  in  the  phenomena  present,  and 
digitalis  is  the  remedy,  but  it  sometimes  taxes  our  ingenuity 
and  resolution  to  give  the  drug  in  a  combination  in  which  it 
can  be  borne.  The  digitoxin  preparations,  such  as  Nativelle's 
digitaHne  and  Hoffmann's  dig-alen,  are  sometimes  usefully 
substituted  for  the  more  Galenic  preparations.  Some  patients 
may  take  strophanthus  better  than  digitalis,  and  the  changes 
may  be  rung  upon  these  two  drugs.  Convallaria  may  be  tried 
as  an  alternative,  but  is  by  no  means  equal  to  either  of  the 
preceding  in  influencing  heart  and  vessels.     In  the  employ- 


PULMONARY   VESICULAR   EMPHYSEMA  281 

ment  of  these  medicines' pains  should  be  taken  to  specify  such 
preparations  as  are  standardised  and  reliable. 

Aerotherapentics. — Much  has  been  written  and  many  obser- 
vations made  upon  the  treatment  of  emphysema  and  allied 
complaints  by  means  of  compressed  and  rarefied  air.  The 
idea  is  no  new  one,  having  been  advocated  by  Nathaniel  Hen- 
shaw  in  the  seventeenth  century  in  his  interesting  little  work 
entitled  "  Aero-Chalinos ;  or,  A  Register  for  the  Air,"^^  but  it 
is  chiefly  to  Waldenburg"  that  we  are  indebted  for  the  modern 
employment  of  the  method.  Theoretically,  expiration  into 
rarefied  air  would  appear  in  emphysema  the  more  hopeful 
method,  the  rarefaction  tending  to  extract  the  air  from  the 
distended  lungs,  and  thus  render  easier  the  succeeding  inspira- 
tion. In  practice,  however,  better  results  are  obtained  from 
the  use  of  compressed  air.  The  treatment  may  be  carried  out 
in  two  ways :  the  patient  may  use  a  portable  apparatus,  of 
which  Waldenburg's  modification  of  Hutchinson's  spirometer 
is  the  best  known,"  and  by  means  of  an  appropriate  adjust- 
ment secure  the  due  compression  or  rarefaction  of  the  air  to 
be  respired.  Experience  has,  however,  hardly  borne  out  the 
hopeful  results  at  first  claimed  from  the  use  of  such  instru- 
ments, and  as  the  continual  adjustment  of  the  necessary 
mouthpiece  is  often  unpleasant  to  the  patient,  the  method  is 
now  but  little  used. 

More  satisfactory  results  are  obtained  by  the  use  of  the  com- 
pressed-air bath,  in  which  the  whole  body  of  the  patient,  and 
not  merely  the  surface  of  his  respiratory  tract,  is  subjected  to 
the  influence  of  the  compressed  air.  Since  the  early  experi- 
ments of  Tabarie  the  method  has  been  gradually  improved, 
until  the  present  satisfactory  chambers  have  been  devised. 
These  may  be  seen  at  numerous  places  on  the  Continent,  and 
notably  at  Reichenhall,  in  Bavaria.  A  detailed  description  of 
the  one  installed  at  the  Brompton  Hospital  will  be  found  in 
Dr.  Theodore  Williams's  work  on  "  Aerotherapeutics.""" 
It  consists  essentially  of  a  chamber  made  of  wrought  iron 
yV  inch  thick,  provided  with  iron  door  and  plate-glass  windows, 
sufficiently  strong  to  resist  the  pressure  to  which  the  whole 
will  be  subjected,  and  containing  chairs  and  tables  for  the  con- 
venience of  the  patients.  The  chamber  is  provided  with  a 
pump  for  compressing  the  air  (worked  in  this  case  by  steam), 
and  a  receiver  containing  cotton-wool,  through  which  the  air 


282  DISEASES   OF  THE  LUNGS   AND  PLEURA 

is  filtered.  It  may  be  made  of  any  size;  that  at  the  Brompton 
Hospital  will  accommodate  three  or  four  patients,  whilst 
others  have  been  constructed  to  hold  twenty. 

The  patient  takes  his  seat  in  the  chamber,  prepared  for  a 
stay  of  two  hours.  The  pressure  of  the  air  is  then  very  gradu- 
ally raised,  until  at  the  end  of  half  an  hour  it  exceeds  the 
normal  by  ten  pounds,  or  two-thirds  of  an  atmosphere.  At 
this  point  it  is  allowed  to  remain  for  an  hour,  and  is  then 
gradually  reduced,  until  at  the  end  of  the  second  hour  the 
normal  has  again  been  reached.  If  care  be  not  taken  to  alter 
the  pressure  very  gradually,  various  unpleasant  sensations 
referable  to  the  throat  and  membrana  tympani  will  be  experi- 
enced; but  no  danger  of  caisson  disease  need  be  anticipated, 
since  to  produce  the  latter  affection  it  has  been  shown  that  a 
reaction  from  a  pressure  exceeding  three  atmospheres  is 
necessary. 

The  baths  should  be  given  every  other  day  at  first,  and 
then  every  day,  a  course  lasting  from  six  weeks  to  two  months, 
after  which  they  may  be  continued  at  longer  intervals. 

As  a  result  of  this  treatment,  there  can  be  no  doubt  that  cer- 
tain cases  of  emphysema  do  improve  considerably.  The 
cough  and  expectoration  lessen,  the  chest  diminishes  in  cir- 
cumference, and  cardiac  and  liver  dulness  tend  to  return  to 
the  normal ;  the  breathing  at  the  same  time  improves,  so  that 
the  patient  is  able  without  distress  to  take  exercise,  which 
before  would  have  been  impossible.  How  exactly  these 
changes  are  brought  about  is  not  quite  clear;  it  may  be  that 
they  result  from  a  beneficial  action  of  the  compressed  air  upon 
the  bronchi,  leading  to  a  constriction  of  their  bloodvessels  and 
a  diminution  of  secretion  and  spasm,  rather  than  from  any 
direct  action  upon  the  alveoH  themselves. 

Favourable  results,  such  as  we  have  described,  must  not, 
however,  be  looked  for  in  every  case;  nor  can  it  be  predicted 
from  the  symptoms  or  physical  signs  what  the  result  will  be 
in  any  given  instance.  Although  the  method  of  treatment  is 
empirical,  it  is  one,  nevertheless,  which  may  be  tried  if  the 
requisite  facilities  are  available. 

Climatic  Treatment. — It  is  generally  held  that  elevated 
climates  are  unsuitable  for  patients  with  emphysema,  inasmuch 
as  such  patients  must  breathe  more  deeply  to  obtain  the 
same  amount  of  oxygen  from  a  rarefied  atmosphere.     From 


PULMONARY   VESICULAR   EMPHYSEMA  283 

the  following  considerations,  however,  it  would  appear 
that  such  an  atmosphere  is  much  less  unsuitable  to 
emphysematous  patients  than  one  might  at  first  assume. 
In  the  first  place,  it  must  be  remembered  that  with  an  abun- 
dant air-supply  only  a  very  small  proportion  of  the  oxygen  is 
used  for  respiratory  purposes;  in  other  words,  expired  air  is 
not  nearly  exhausted  of  its  oxygen.  Secondly,  although  the 
air  of  elevated  regions  is  rarefied,  its  particles  are  more  actively 
mobile,  and  oxygenation  is  relatively  quickened ;  thus,  Tyndall 
and  Frankland^^  demonstrated  that  the  loss  of  weight  of  a 
candle  burning  on  Mont  Blanc  at  an  elevation  of  12,000  feet  is 
identically  the  same  as  that  of  another  candle  of  similar  dimen- 
sions burning  in  the  valley  of  Chamounix  below.  Thirdly, 
the  circulation  through  the  lungs,  as  elsewhere,  is  carried  on 
at  less  pressure  in  elevated  regions,  and  the  heart,  tuned 
originally  to  lower  latitudes,  finds  relief  in  this  way. 

The  above  considerations  are  interesting,  because  they  show 
that  on  theoretical  grounds  a  certain  amount  of  emphysema 
need  be  no  bar  to  residence  in  a  higher  altitude  if  this  be 
otherwise  indicated.  And  this  agrees  with  our  practical  ex- 
perience, for  we  have  known  not  a  few  cases  of  chronic  phthisis 
with  varying  degrees  of  emphysema  to  do  well  in  the  High 
Alps.  Nevertheless,  we  should  not  advise  such  climates  for 
the  more  usual  cases  of  chronic  bronchitis  and  emphysema. 
For  these,  a  warm  climate  near  the  sea-level  is  to  be  recom- 
mended, where  the  patient  may  take  sufBcient  exercise  with- 
out the  exertion  of  hill-climbing,  and  where  the  danger  of 
recurrent  attacks  of  bronchitis  is  diminished  as  far  as  possible. 
Such  conditions  are  to  be  found  at  many  of  our  own  health 
resorts,  such  as  Falmouth,  Ventnor,  or  St.  Leonards ;  or  abroad 
at  such  stations  as  Mentone,  Bordighera,  or  San  Remo,  on 
the  Riviera.  In  Egypt,  Grand  Canary,  or  Madeira,  the  con- 
ditions are  also  favourable. 

Surgery. — During  the  last  few  years  an  attempt  has  been 
made,  notably  by  Professor  Delbet,  of  Paris,  to  deal  sur- 
gically with  emphysema^^  by  the  performance  of  chondrec- 
tomy — that  is  to  say,  the  excision  of  certain  rib  cartilages  with 
their  perichondrium,  on  the  assumption  that  loss  of  elasticity 
of  the  framework  of  the  chest  referred  to  by  Freund  (see 
p.  274)  is  the  most  important  element  in  the  malady.  In  certain 
cases  relief  has  been  given,  but  the  operation  is  not  free  from 


284  DISEASES    OF   THE   LUNGS   AND   PLEURAE 

danger,  and  we  believe  that  the  cases  are  rare  in  which  such 
treatment  can  justifiably  be  entertained. 


Interstitial  or  Interlobular  Emphysema. 

This  condition  depends  on  the  escape  of  air  into  the  connec- 
tive tissue  surrounding  the  lobules,  bronchioles,  bronchi,  and 
bloodvessels,  and  also  that  beneath  the  pleura.  It  is  caused 
by  wounds  of  the  lung  tissue,  or  by  rupture  of  the  air-vesicles 
during  severe  attacks  of  cough  or  other  straining  efforts.  It 
is  most  common  in  childhood  during  the  paroxysms  of  whoop- 
ing-cough and  other  diseases  associated  with  violent  and  pro- 
longed coughing,  but  we  have  known  it  to  occur  in  the  course 
of  phthisis. 

If  limited  to  the  lung,  the  air  appears  as  small  beads  in  the 
interlobular  tissue;  but  under  the  pleura  it  may  form  blebs  of 
considerable  size  (Plate  XV.).  It  further  tends  to  pass  into 
the  mediastinum,  and  thence  into  the  cellular  tissue  of  the  neck, 
producing  surgical  emphysema,  whence  it  may  even  extend 
over  the  trunk.  In  rare  cases  it  has  led  to  pneumothorax.  If 
left  alone  the  air  is  usually  absorbed,  but  if  there  is  great  ten- 
sion this  may  be  relieved  by  puncture  or  incision  of  the  skin, 
when  the  air  escapes. 

If  uncomplicated  and  limited  to  the  lung,  the  condition  gives 
rise  to  no  clinical  symptoms  or  physical  signs,  and  is  only  dis- 
covered at  the  autopsy. 

REFERENCES. 

'  (a)  A   Manual  of  Pathological  Histology,  by  Dr.    Eduard  Rindfleisch 
(New  Sydenham  Society  edition),  vol.  ii.,  p.  7.     London,  1873. 
{h)  Loc  cit.,  p.  7. 

^  (i)  "The  Mechanism  of  Respiration  in  Man,"  by  Arthur  Keith,  M.D. 
(with  bibliography),  being  an  article  in  Further  Advances  in  Physi- 
ology, edited  by  Leonard  Hill,  M.B.,  F.R.S.,  p.  182.     London,  1907. 
(2)   "Why  does  Phthisis  attack  the  Apex  of  the  Lung?"   by   Arthur 
Keith,  M.D.,  The  London  Hosfital  Gazette,  January,  1904. 

^  See  article  on  "  Emphysema  and  Atelectasis,"  by  Prof.  Friedrich  A. 
Hoffmann,  in  Nothnagel's  Encyclopedia  of  Practical  Medicine  (English 
edition),  edited  by  John  H.  Musser,  M.D.,  pp.  258-263.  Philadelphia  and 
London,  1903. 

*  "  On  the  Determining  Causes  of  Vesicular  Emphysema  of  the  Lung," 
by  William  Jenner,  M.D.,  F.R.C.P.,  Transactions  of  the  Royal  Medicql 
Qnd  Chirurgical  Society,  1857,  vol.  xl.,  p.  25, 


PLATE  XV 


INTERSTITIAL  EMPHYSEMA 

On  the  surface  of  the  lung  numerous  air-bubbles  are  seen,  from 
the  rupture  of  alveoli  and  the  escape  of  air  into  the  tissues 
beneath  the  pleura. 

From  a  male  child  aged  nine  and  a  half  months,  who  died 
from  whooping-cough.  The  section  of  the  lung  showed  patches 
of  broncho-pneumonia,  but  no  vesicular  emph^'sema. 


(From  the  Museum  of  St.  Bartholomew's  Hospital. 
Natural  size.) 


PLATE  XV 


Interstitial  Emphysema. 


To  face  p. 


PULMONARY   VESICULAR   EMPHYSEMA  285 

*  Traiti  de  V Auscultation  Mediate  et  des  Maladies  des  Poumons  et  du 
(Jceur,  par  R.  T.  H.  Laennec,  troisieme  edition,  tome  i.,  p.  292.  Paris, 
1831. 

^  On  the  Pathological  Anatotny  of  Bronchitis,  and  the  Diseases  of  the 
Lung  connected  with  Bronchial  Obstruction,  by  W.  T.  Gairdner,  M.D., 
p.  57,  etc.     Edinburgh,  1850. 

'  Medical  Lectures  and  Aphorisms,  by  Samuel  Gee,  M.D.,  fourth  edition, 
p.  127.     London,  1915. 

*  On  Bronchitis  and  the  Morbid  Conditions  connected  ivith  it,  by 
Edward  Headlam  Greenhow,  M.D.,  F.R.S.,  second  edition,  pp.  233-237. 
London,  1878. 

°  Der  Zusammenhang  gewisser  Lun genkr ankheiten  mit  frimdren  Ri-pfen- 
knor-pel-Anomalieen,  von  Dr.  Wilhelm  Alexander  Freund  (zu  Breslau). 
Erlangen,  1859. 

'"  Die  P nemnatometrie  und  Sfirometrie,  von  Dr.  L.  Waldenburg,  p.  56, 

1880. 

"  See  cases  recorded  by  [a]  the  late  Professor  Coats,  Manual  of 
Pathology,  by  Joseph  Coats,  M-D.,  p.  739  (London,  1895);  also  [b]  by 
Dr.  Wethered,  "A  Case  of  Hypertrophy  of  the  Lung,"  by  Frank  J. 
Wethered,  M.D.,  Transactions  of  the  Pathological  Society  of  London,  1897, 
vol.  xlviii.,  p.  34. 

'^  Aero-Chalinos :  or,  A  Register  for  the  Air,  by  Nathaniel  Henshaw, 
M.D.,  F.R.S.,  the  second  edition.  Printed  for  Benj.  Tooke  at  the  Ship 
in  St.  Paul's  Churchyard,  London,  1677. 

"  Die  Pneumatische  Behandlung  der  Respirations-  und  Circulations- 
Tzr ankheiten,  in  Anschluss  an  die  Pneumatotnetrie,  Sfirometrie  und  Brust- 
messung,  von  L.  Waldenburg.     Berlin,  1875. 

'*  See  [a]  Aerotherapeutics,  by  Charles  Theodore  WiUiams,  M.D.,  p.  98, 
London,  1894. 

[b]  "  Artificial  Aerotherapeutics,"  by  C.  Theodore  WiUiams, 
AI.D.,  Allbutt  and  Rolleston's  System  of  Medicine,  vol.  v.,  p.  35. 
London,   1909. 

'^  See  On  the  Curative  Effects  of  Baths  and  Waters,  by  Dr.  Julius  Braun, 
edited  by  Hermann  Weber,  M.D.,  p.  59.     London,  1875. 

'"  See    [a)    "  Freund's    Operation    in    Pulmonary    Emphysema,"    British 
Medical  Journal,  January  8,   1910,  epitome  No.  20,  p.  6. 
{b)    "  Le   Thorax   et   I'Emphyseme  :    la   Chondrectomie,"    par    E. 
Douay,    Annales    de    la    Clinique    Chirurgicale    du    F'rofesseur 
Pierre  Delbet.     Paris,    1914. 

[c]  "  Operation  for  Emphysema,"  British  Medical  Journal,   1916, 
vol.  ii.,  p.   428. 

[d]  Surgery  of  the  Lung  and  Pleura,  by  H.  Morriston  Davies, 
M.A.,  M.D.,  M.C.,  F.R.C.S.,  p.  246. 


CHAPTER  XVII 

PNEUMONIA 

Acute  lobar  pneumonia,  or,  as  it  is  inaptly  termed  by  German 
writers,  "croupous  pneumonia,"  may  be  defined  as  an  acute 
specific  disease,  characterised  by  inflammatory  consolidation 
of  some  portion  of  one  or  both  lungs. 

In  a  sense,  pneumonia  and  inflammation  of  the  lungs  are 
synonymous  terms,  but  the  latter  expression  by  no  means 
covers  the  whole  pathology  of  the  disease.  In  many,  if  not 
in  all  cases  the  micro-organisms  responsible  for  the  malady 
pass  into  the  blood-stream,  and  under  certain  conditions  specific 
complications  in  distant  organs,  such  as  the  meninges  of  the 
brain  or  the  internal  ear,  result.  In  all  cases,  too,  the  poisons 
elaborated  in  the  lungs  are  rapidly  absorbed,  and  to  their  toxic 
effects  many  of  the  most  characteristic  symptoms  are  due.  In 
every  case,  therefore,  the  disease  affects  the  whole  system  to  a 
greater  or  less  extent,  and  any  conception  which  regards  it  as 
limited  to  the  lungs  must  be  erroneous.  We  have  to  deal, 
in  fact,  in  pneumonia,  with  a  blood  infection  as  well  as  a  local 
inflammation. 

.etiology — Individual  Predisposition. — No  age  is  exempt 
from  pneumonia,  but  the  malady  is  more  prevalent  at  that 
period  between  twenty  and  forty,  when  persons  are  most  ex- 
posed in  the  active  struggle  of  life.  The  male  sex  is  more 
frequently  attacked  than  the  female  in  proportion  of  three  to 
two,  and  at  the  period  of  life  referred  to  the  prevalence  is 
twice  as  great  amongst  males  (Longstaff^).  Depressed 
vitality,  arising  from  debauchery,  intemperance,  over-fatigue, 
anxiety,  insufficient  food,  or  overcrowding,  renders  the  in- 
dividual more  prone  to  attack.  Some  persons  are  especially 
liable  to  the  disease,  and  one  attack  favours  the  disposition 
to  future  recurrences.  In  rare  cases  as  many  as  thirteen, 
fifteen,  sixteen,  or  even  twenty-eight  attacks  have  been 
recorded.-'" 

Pre-existing  Diseases. — Chronic  disease  of  any  kind,  but 

286 


PNEUMONIA  287 

especially  alcoholism,  albuminuria,  and  gout,  increases  the 
liability  to  pneumonia.  But,  curiously  enough,  the  presence 
of  already  existing  chronic  lung  affections,  such  as  phthisis, 
asthma  or  bronchitis,  does  not  appear  to  render  the  subject 
more  liable  to  the  disease.  A  plethoric  state  of  body  seems 
to  favour  its  occurrence,  and  to  add  much  to  the  severity  of 
the  attack.  Surgical  injury  and  the  shock  resulting  from 
severe  accidents  are  not  infrequently  followed  by  its  appear- 
ance, especially  in  old  people. 

Climatic  Influences. — Cold  seasons,  great  variations  of  tem- 
perature and  rough  piercing  winds  bring  about  pneumonia. 
The  disease  is  thus  comparatively  rare  during  the  summer 
from  June  to  October,  but  with  the  advent  of  winter  its 
frequency  increases,  until  its  maximum  incidence  is  reached 
in  February  or  March,  when  in  this  country  the  east  winds  are 
most  severely  felt. 

It  is  to  be  observed  that  a  merely  low  external  temperature 
is  not  so  favourable  to  the  occurrence  of  pneumonia  as  ex- 
posure to  great  variations.  Indeed,  it  is  stated  that  pneu- 
monia is  more  common  in  hot  than  in  cold  climates.  Chill 
from  undue  exposure  to  draughts,  cold  winds,  and  the  like, 
is  the  most  common  exciting  cause  of  pneumonia,  and 
the  disease  not  infrequently  arises  in  workmen  who,  getting 
warm  at  their  work  in  the  sunshine  of  a  May  day,  throw 
off  coverings  and  become  chilled  by  a  north  or  north- 
east wind,  of  which  they  were  before  unconscious.  Not  only 
are  most  of  the  sporadic  cases  to  be  accounted  for  in  this  way, 
but  a  certain  number  of  the  epidemic  occurrences  of  the 
disease  in  modern  times  are  thus  explained,  individual  suscep- 
tibility and  special  exposure  being  the  predisposing  circum- 
stances. The  epidemic  related  by  Assistant-Surgeon  Welch^ 
as  affecting  the  22nd  Regiment,  stationed  at  New  Brunswick, 
may  be  quoted  as  an  example.  The  troops,  who  had  been 
stationed  at  Malta  for  six  years,  were  transferred  during  cold 
wintry  weather  to  New  Brunswick.  Of  the  total  strength  of 
652  men,  52  were  soon  attacked  with  pneumonia,  12  cases 
occurring  in  January,  the  month  of  greatest  cold,  and  31  in 
February  and  March,  when  temperature  fluctuations  were 
most  marked.  Of  the  652  men,  330  were  housed  in  the 
"Exhibition  building,"  a  large,  cold,  draughty  wooden  struc- 
ture, freely  exposed  on  all  sides,  and  of  these  38  (or  11-5  per 


288  DISEASES   OF  THE  LUNGS   AND   PLEURA 

cent.)  developed  the  disease.  The  remaining  322  were 
quartered  in  suitable  and  warmer  barracks,  or  in  married 
quarters,  and  of  these  only  13  (or  4  per  cent.)  were  affected; 
whilst  among  152  women  and  children  only  2  cases  occurred. 
Of  the  whole  52  cases,  Welch  attributed  27  to  cold  draughts 
and  lowness  of  general  temperature,  7  to  sleeping  on 
mattresses  carelessly  stuffed  with  damp  snowed  straw,  5  to 
exposure  to  great  cold  at  night,  and  6  to  chill  whilst  perspir- 
ing from  strong  exercise.  In  the  remaining  7  cases  the  direct 
exciting  cause  was  obscure.  The  facts  here  recorded  are 
striking,  and  emphasise  the  important  part  played  by  "ex- 
posure "  in  the  production  of  the  disease. 

Injury. — In  a  small  proportion  of  cases  a  blow  on  the  chest 
has  seemed  to  be  the  direct  exciting  cause  of  acute  pneumonia, 
and  such  cases  have  been  styled  "traumatic"  or  "contu- 
sional  "  pneumonia.*  But,  apart  from  these,  we  have  met  with 
cases  that  have  been  apparently  attributable  to  the  shock 
following  injury  to  another  part  of  the  body,  and  we  may 
note  that  a  similar  phenomenon  has  been  observed  in  the  case 
of  massive  collapse  of  the  lung  (see  p.  346). 

Septic  Influences.— 2E.\.\o\ogicdi\  researches,  and  especially 
the  evidence  brought  together  by  the  Committee  of  Collective 
Investigation  of  the  British  Medical  Association/  leave  no 
room  for  doubt  that  cases  and  groups  of  cases  of  pneumonia 
are  to  be  met  with  which  are  dependent  upon  faulty  sanitary 
conditions,  and  especially  exposure  to  sewer-gas  emanations. 
Whenever  several  persons  in  a  house  are  attacked,  either 
together  or  in  quick  succession,  the  possibility  of  such 
a  cause  should  at  once  suggest  itself.  The  disease,  when  thus 
arising,  is  apt  to  be  of  a  somewhat  different  type  from  the 
more  ordinary  variety,  and  merits  the  term  "septic  pneu- 
monia," under  which  we  shall  describe  it. 

Direct  Infection. — There  is  evidence  to  show  that,  under 
certain  circumstances,  pneumonia  may  be  communicated 
directly  by  one  person  to  another.  The  Collective  Investigation 
Committee,  in  answer  to  a  special  request  for  information  as  to 
the  aetiology  of  pneumonia,  received  about  one  hundred  replies, 
in  eighty  of  which  no  other  cause  than  exposure  to  cold  could 
be  assigned  for  the  attack.  The  twenty  remaining  replies  are 
abstracted  in  the  Record^"  and  amongst  them  nine  observa- 
tions are  included  in  which  there  was  apparent  transmission 


PNEUMONIA  289 

of  the  disease  from  one  member  of  a  family  to  others,  in  at 
least  one  of  which  the  evidence  is  very  strong. 

The  difficulty  is,  of  course,  the  usual  one  of  separating  cases 
of  several  persons  being  attacked  in  consequence  of  exposure 
to  a  common  cause  from  those  in  which  the  first  attacked  has 
transmitted  the  disease  to  others.  In  the  epidemic  at  New 
Brunswick  already  referred  to  no  suspicion  of  communication 
of  the  disease  by  infection  is  mentioned,  and  similarly  with 
one  of  the  two  epidemics  described  by  Surgeon-Major 
Maunseir  in  North- West  India.  Several  striking  instances 
of  the  apparent  origin  of  pneumonia  by  contagion  are,  how- 
ever, quoted  by  Drs.  Sturges  and  Coupland^  from  various 
authors,  and  others  have  since  been  recorded.'  Some  of  these 
are  convincing,  as  when  a  person  has  acquired  the  disease 
after  nursing  a  sufferer  from  pneumonia,  and,  having  been 
sent  to  a  distant  home,  other  cases  have  at  once  arisen  among 
the  members  of  the  fresh  family  previously  in  perfect  health. 
Cases  such  as  these — and  not  a  few  have  now  been  recorded — 
are  difficult  to  put  aside,  and  we  must  conclude  that  in 
certain  circumstances,  when  the  virus  is  especially  active  or 
the  system  more  than  usually  receptive,  the  disease  may  be 
spread  by  direct  infection.  Indeed,  it  is  not  improbable  that, 
were  the  sputum  in  pneumonia  less  viscid,  and  were  it  there- 
fore easier  for  infected  droplets  to  be  coughed  into  the  air, 
and  thus  inhaled,  the  disease  would  be  more  often  communi- 
cated in  this  manner.  In  this  connection  it  should  be  noted 
that  the  pneumococci  responsible  for  the  attack  disappear 
from  the  mouth  as  a  rule  within  three  to  four  weeks  after 
recovery,  but  they  have  been  known  to  persist  as  long  as  three 
months."'' 

Bacteriology. — Bacteriological  research  has  demonstrated 
that  in  the  great  majority  of  cases  of  lobar  pneumonia,  perhaps 
95  per  cent,  the  pneumococcus  discovered  by  Talamon  and 
further  studied  by  Frankel  is  to  be  found  in  the  lung,  and 
often  it  is  the  only  organism  present.  That  it  is  capable  of 
producing  pneumonia  is  shown  by  the  fact  that  if  a  culture 
be  injected  into  the  lung  of  a  sufficiently  resistant  animal, 
such  as  the  dog  or  sheep  (Gamaleia"),  acute  lobar  pneumonia, 
identical  with  that  occurring  in  man,  results.  We  are  justified, 
therefore,  in  regarding  the  pneumococcus  as  the  specific  cause 
of  the  disease  in  the  vast  majority  of  cases. 

19 


290  DISEASES   OF  THE  LUNGS   AND   PLEUR/E 

In  a  small  percentage  of  patients  other  organisms  may  be 
responsible,  such  as  the  pneumo-bacillus  of  Friedlander,  which 
has  occasionally  been  found  in  pure  culture  in  the  lung,  or  the 
pyogenic  cocci  which  are  sometimes  alone  present  in  so-called 
"septic  pneumonia." 

The  preponderant  role  played  by  the  pneumococcus  in 
cases  of  acute  lobar  pneumonia  is  demonstrated  by  the  follow- 
ing figures,  which  give  the  setiological  agents  concerned  in 
480  cases  of  the  disease  treated  at  the  hospital  of  the  Rocke- 
feller Institute  in  New  York,  in  which  the  bacteriological 
findings  were  fully  worked  out 


10* 


Diplococcus  pneumoniae 

Friedlander 's  bacillus 

Pfeiffer's  bacillus  (of  influenza) 

Streptococcus  pyogenes 

Streptococcus  mucosus 

Staphylococcus  aureus 

Mixed  infections,  with  combinations  of  Staphylo- 
coccus aureus,  Friedlander's  bacillus,  Pfeiffer's 
bacillus,  Streptococcus  pyogenes,  and  Streptococcus 
viridans 


454 
3 
6 

7 


Total  ...  ...  ...  ...    480 

In  the  sputum  or  in  films  made  from  the  pneumonic 
exudation  the  pneumococcus  presents  the  appearance  of  small 
cocci,  often  arranged  in  pairs,  the  two  ends  of  which  are 
generally  somewhat  pointed.  It  thus  acquires  a  lancet-shaped 
appearance,  and  has  been  accordingly  termed  the  Diplococcus 
lanceolatus.  The  organism  stains  by  Gram's  method,  and, 
when  growing-  in  the  tissues,  is  surrounded  by  a  definite  and 
characteristic  capsule.  To  demonstate  this  in  the  sputum,  a 
portion  should  be  dried  on  a  cover-glass  and  stained  with 
methylene  blue,  then  washed  and  mounted  in  water.  In  this 
way,  as  the  late  Professor  Kanthack  showed,  the  capsule  is 
easily  brought  into  view.  At  a  temperature  of  37°  C.  cultures 
may  be  obtained  without  great  difficulty,  and  on  agar  they 
present  a  characteristic  appearance,  forming  small  round 
transparent  masses,  which  have  been  compared  to  drops  of 
dew.     Below  24°  C.  but  little  growth  occurs. 

Pneumococci  are  most  easily  demonstrated  in  those  areas 
of  the  lung  which  are  in  the  earliest  stage  of  the  pneumonic 
process  and  in  a  condition  of  acute  inflammatory  congestion. 
But  they  are  not  confined  to  the  lung,  and  may  be  found  in 


PNEUMONIA  291 

the  pleura  or  pericardium,  when  these  tissues  have  become 
infected  and  inflamed  by  direct  extension.  Often  also  they 
are  present  in  the  blood,  and  in  this  way  may  be  responsible 
for  a  malignant  endocarditis,  a  meningitis,  an  otitis  or  arthritis, 
or  some  other  and  distant  complication. 

We  have  spoken  hitherto  as  though  the  pneumococcus  were 
a  single  organism  of  unvarying  character,  but  recent  re- 
searches at  the  Rockefeller  Institute  in  New  York  have 
revealed  that,  just  as  in  the  case  of  the  streptococcus  and  the 
colon  bacillus,  more  than  one  type  of  pneumococcus  may  be 
recognised.  Differentiation  of  the  strains  can  be  made  by  the 
agglutination  test,  using  sera  prepared  by  the  inoculation  of 
various  strains  of  pneumococci,  and  in  this  way  three  types 
(I.,  II.,  and  III.)  may  be  easily  separated.  A  fourth  variety, 
which  does  not  agglutinate  with  any  of  the  standard  sera,  but 
which,  like  other  pneumococci,  is  soluble  in  bile,  has  also  been 
isolated.  The  following  table,  taken  from  the  valuable  mono- 
graphs of  the  Rockefeller  Institute  to  which  we  have  referred, 
shows  the  frequency  of  occurrence  in  New  York,  as  well  as 
the  percentage  mortality,  caused  by  each  variety  or  type  :  "^ 

Incidence  in  New  York  of  Various  Types  of  Pneumococcus  and 

resulting  mortality. 

Type. 

I 

II. 
III. 
IV. 

We  thus  see  that  pneumococci  of  Types  I.  and  II.  are 
responsible  for  64  per  cent,  of  all  cases  of  acute  lobar  pneu- 
monia occurring  in  New  York,  and  that  the  majority  of  deaths 
from  this  disease  are  due  to  their  agency.  Few  cases  of 
pneumonia  are  produced  by  organisms  of  Type  III.,  but  their 
virulence  is  great,  and  nearly  half  the  patients  attacked  die. 
Type  IV.  is  responsible  for  nearly  a  quarter  of  the  cases  of 
pneumonia,  but  the  mortality  is  less,  a  fatal  termination 
occurring  in  only  16  per  cent,  of  those  attacked.  An  identifica- 
tion of  the  type  of  pneumococcus  present  in  any  given  case 
has  thus  an  obvious  bearing  upon  prognosis,  as  well  as  upon 
the  question  of  specific  treatment,  to  which  we  shall  refer 
later.  We  may  add  that  in  the  pneumonia  which  occurs  so 
frequently  in  South  Africa  among  the  natives  working  in  the 


Incidence. 
Per  Cent. 

Mortality 
Per  Cent, 

33 
31 
12 
24 

25 

32 

45 
i5 

292  DISEASES   OF  THE  LUNGS   AND   VLEVRJE 

gold  mines,  Dr.  F.  S.  Lister'^  has  established  other  varieties 
of  pneumococci,  in  addition  to  those  discovered  by  the 
workers  at  the  Rockefeller  Institute,  one  of  which  he  finds  to 
be  of  frequent  occurrence  and  of  high  case  mortality. 

In  addition  to  being  present  in  the  tissues  of  patients  suffer- 
ing from  pneumonia,  the  pneumococcus,  as  Pasteur"  first 
showed,  may  be  found  in  the  saliva  of  not  a  few  healthy 
people  (Netter^*).  The  researches  of  the  Rockefeller  Insti- 
tute would  appear  to  indicate  that  such  pneumococci  belong 
for  the  most  part  to  Type  IV.,  the  least  virulent  of  the  various 
strains,  and  that,  except  in  convalescents  and  "contacts," 
organisms  of  Types  I.  and  II.,  which  are  responsible  for  the 
majority  of  cases  of  pneumonia,  are  but  rarely  met  with. 
Nevertheless,  the  fact  that  pneumococci  do  occur  in  the 
mouths  of  nearly  40  per  cent,  of  normal  persons"'^  is  a  fact 
which  helps  to  elucidate  a  good  deal  that  has  hitherto  appeared 
obscure  in  the  aetiology  of  pneumonia,  and  it  is  not  difficult 
to  understand  how  cold,  wasting"  diseases,  or  alcoholism  may 
predispose  or  give  rise  to  the  disease,  provided  the  specific 
germ  is  already  present  within  the  body,  ready  to  take 
advantage  of  the  local  vascular  changes  or  lowered  resistance 
which  favour  its  growth. 

Pathology  and  Morbid  Anatomy.— The  morbid  anatomy  of 
pneumonia  consists,  in  the  first  place,  of  an  acute  hypersemia 
of  the  affected  lung,  resulting  in  a  fibrino-corpuscular  exuda- 
tion into  the  alveoli,  sometimes  including  the  smaller  bron- 
chioles, and  forming  a  film  upon  the  pleural  surface.  This 
exudation,  coagulating  in  situ,  fixes  the  lung  in  a  state  of 
immovable  expansion,  more  densely  solidified  than  it  could 
be  by  any  artificial  injection  with  coagulable  fluid.  In  the 
attainment  of  this  second  stag-e  of  "hepatisation"  all  the 
severity  of  the  disease  is  manifested,  and  on  its  completion 
the  disease  proper  is  at  an  end.  Thirdly,  with  liquefaction  and 
absorption  of  the  morbid  products,  convalescence  becomes 
established. 

A  normal  pneumonia  is  thus  artificially  divisible  into  three 
stages. 

The  first  stage  begins  with  the  rigor,  and  ends  with  the 
appearance  of  definite  signs  of  consoHdation.  It  may  be 
termed  the  stage  of  initial  fever  with  pulmonary  engorge- 
ment, and  it  lasts  from  two  to  five  days.     If  death  should 


PNEUMONIA 


293 


occur  at  this  stage,  the  affected  lung  is  found  to  be  in  a  condi- 
tion of  inflammatory  oedema,  heavy,  engorged  with  florid 
blood,  pitting  on  pressure,  and  still  crepitating.  On  section, 
abundant  blood-stained  and  frothy  serum  exudes.  Pulmonary 
hyperaemia  and  fluid  exudation  are  the  conditions  present. 
When  the  pneumonia  occurs  in  very  cachectic  subjects, 
scattered  pulmonary  haemorrhages  may  be  found.  A  mere 
outburst  from  engorged  vessels  at  some  one  time,  however, 
is  not  necessarily  associated  with  disease  of  a  specially  low 


Fig.  29. — Section  of  Lung  in  Pneumonia  -.  Latter  Period  of  Red 

Hepatisation. 

type.  It  must  be  observed  that  throughout  the  febrile  period 
of  pneumonia  there  is  an  advancing  area  of  lung  thus  affected. 
The  second  stage  —  that  of  pulmonary  hepatisation  — 
emerges  from  the  former,  and  terminates  in  from  forty-eight 
hours  to  five  or  six  days.  It  is  characterised  by  continued 
high  temperature,  and  by  increasing  signs  of  consoHdation 
of  lung.  In  this  stage  of  red  hepatisation  the  affected  portion 
of  lung  is  bulky,  heavy,  and  solid  to  the  feel.  The  pleural 
surface  is  more  or  less  covered  with  a  thin  layer  of  soft,  finely 
granular  lymph  which  can  be  readily  scraped  off,  exposing  the 
glistening  pleura  beneath.  In  some  cases  this  layer  is  com- 
plete, of  some  thickness,  and  of  yellowish  opacity.     On  sec- 


294  DISEASES   OF  THE  LUNGS   AND   PLEURA 

tion,  the  lung  is  firm  and  dry,  presenting  a  red  granular 
surface,  which  is  readily  broken  by  the  pressure  of  the  finger. 
A  little  frothy  secretion  may  be  present  in  the  bronchial  tubes, 
the  mucous  membrane  of  which  is  injected.  If  the  cut  surface 
be  scraped,  and  the  juice  thus  obtained  be  examined,  casts  of 
the  alveolar  passages  and  bronchioles  will  be  found.  A 
portion  cut  from  the  consolidated  lung  sinks  at  once  in  water. 

A  thin  section  from  the  consolidation  shows  the  alveoli, 
infundibula,  alveolar  passages,  and  sometimes  the  smallest 
divisions  of  the  bronchi,  to  be  occupied  by  red  blood-discs  and 
leucocytes  entangled  in  the  meshes  of  coagulated  fibrin 
(Fig.  29).  The  alveolar  wall  is  not  changed  beyond  some- 
times showing  slight  swelling  of  its  epithelium,  a  few  cells 
of  which  may  be  shed.  Towards  the  latter  portion  of  this 
stage  there  is  more  or  less  emigration  of  leucocytes  through 
the  alveolar  walls.  In  cases  in  which  the  pulmonary  inflam- 
mation supervenes  upon  long-continued  hypostatic  conges- 
tion the  consolidation  is  softer,  darker,  and  more  spleen-like 
in  appearance,  and  has  been  called  "  splenification  of  lung." 
The  term  "hypostatic  pneumonia"  is  also  applied  to  this 
condition. 

Third  Stage. — That  of  resolution.  The  commencement  of 
this  stage  is  characterised  in  normal  cases  by  a  remarkably 
rapid  fall  of  temperature,  attended  with  profuse  sweatings  or 
other  critical  phenomena,  and  the  signs  of  commencing  lique- 
faction of  the  elements  of  the  lung  consohdation.  The  lung 
now  assumes  a  greyish  aspect,  with  some  red  patches  still 
remaining.  On  section,  the  granular  appearance  is  at  first 
maintained.  Later,  the  whole  lobe  becomes  of  a  dirty  greyish- 
yellow  colour  and  much  softer.  This  stage  of  pneumonia  is 
spoken  of  as  grey  hepatisation. 

The  microscopical  appearances  are  at  first  characterised  at 
this  stage  by  an  extensive  emigration  of  leucocytes.  The 
exuded  products  then  undergo  degeneration,  the  fibrinous 
strands  becoming  completely  disintegrated,  the  red  corpuscles 
decolourised,  and  finally  both  red  and  white  cells  more  or  less 
broken  down  by  fatty  changes.  The  change  in  colour  ob- 
served on  the  post-mortem  table  from  red  to  grey  hepatisa- 
tion is  brought  about  partly  by  these  alterations,  partly 
through  compression  of  the  pulmonary  capillaries  by  the 
pressure  of  the  exudation. 


PNEUMONIA  ^  295 

As  a  rule,  the  alveolar  walls  remain  intact,  beyond,  perhaps, 
manifesting  slight  swelHng  of  their  epithelial  lining,  and  the 
emulsified  products  are  readily  removed,  chiefly  by  absorp- 
tion, but  in  part  also  by  expectoration.  In  some  cases,  hov^- 
ever,  the  texture  of  the  lung  is  involved  in  the  inflammatory 
change,  the  alveolar  v^alls  become  infiltrated  with  leucocytes, 
and  the  reparative  stage  of  grey  hepatisation  is  changed  for 
that  of  suppurative  disintegration  of  the  lung  itself.  This  un- 
toward event,  spoken  of  as  "purulent  infiltration,"  must  be 
regarded  as  a  complication  rather  than  as  a  feature  of  pneu- 
monia. It  is  doubtful  whether  recovery  can  take  place  when 
this  condition  has  been  established.  Should  it  occur  over  a 
localised  area,  an  abscess  of  the  lung  results. 

The  portion  of  lung  affected  in  pfieumonia  is  most  commonly 
the  base  on  one  side,  the  right  being  more  frequently  affected 
than  the  left.  It  is  rare  for  both  bases  to  be  simultaneously 
attacked,  but  it  is  common  for  the  second  base  to  become  in- 
volved in  the  course  of  the  disease.  Perhaps  the  frequency 
with  which  this  happens  has  been  exaggerated  from  the  fact 
that  both  tubular  breath-sound  and  crepitant  rale  may  be 
audible  at  one  base  by  reflection  from  a  corresponding  point  of 
the  other.  The  upper  lobe  is  attacked  in  a  goodly  proportion 
of  cases,  more  commonly  so  in  children  than  adults;  amongst 
the  latter  are  included  the  more  cachectic  cases,  whether  from 
alcohol  or  other  causes,  which  generally  run  a  graver  course. 

It  must  be  borne  in  mind  that  the  above  description  of  the 
three  stages  of  pneumonia  relates  to  the  pathology  of  each 
portion  of  lung  attacked,  but  pneumonia  frequently  attacks 
successive  portions  of  lung,  when  the  morbid  anatomy  and 
symptoms  of  the  three  stages  will  be  confused  and  over- 
lapping. 

It  must  be  further  noted  that,  apart  from  definite  complica- 
tions, a  certain  degree  of  cloudy  swelling  of  the  kidneys,  liver, 
and  heart  is  commonly  to  be  observed,  as  in  other  specific 
fevers.  Some  swelling  of  Peyer's  patches  is  also  occasionally 
noticed. 

Symptomatology. — The  invasion  of  pneumonia  is  generally 
sudden,  and  is  usually  marked  by  a  distinct  rigor.  Often, 
however,  the  attack  is  preceded  by  a  few  days  of  what  may 
be  regarded  as  prodromal  symptoms,  malaise,  bronchial 
catarrh,  anaemia,  coated  tongue,  and  slightly  icteric  tint  of 


296  DISEASES   OF  THE  LUNGS   AND   PLEURA 

skin.  It  is  not  uncommon  for  patients  to  have  been  out  of 
sorts,  depressed,  dyspeptic,  catarrhal,  with  torpid  liver  func- 
tions and  loaded  urine,  for  some  weeks  previous  to  an  attack 
of  pneumonia;  but  this  is  only  another  way  of  saying  that 
they  have  been  qualifying  for  an  acute  illness,  the  exact 
nature  of  which  is  determined  by  other  circumstances,  and 
which,  by  timely  attention  to  the  general  health,  might  have 
been  altogether  avoided. 

In  place  of  the  rigor  which  ushers  in  pneumonia,  there  may 
be,  especially  in  children,  convulsions  or  vomiting.  The  tem- 
perature rises  with  great  rapidity  from  the  time  of  the  rigor; 
severe  headache,  and  even  somewhat  violent  delirium,  may  be 
present;  the  eye  is  as  a  rule  bright,  conjunctivae  sometimes 
icteric,  face  notably  flushed,  breathing  hurried  and  regular, 
and  attended  with  action  of  nares.  The  pulse  is  from  the 
first  always  quickened  in  pneumonia,  and  especially  so  in 
young  people,  but  not  proportionately  to  the  breathing.  It 
must  be  recognised,  however,  that  temperament  and  habitual 
pulse  frequency  have  to  be  taken  into  account  in  estimating 
this  symptom.  There  may  be  severe  gastric  disturbance,  with 
slight  jaundice,  in  the  early  days  of  the  disease.  Of  local 
symptoms,  pain  and  dyspnoea  are  those  which  chiefly  attract 
attention. 

The  general  symptoms  often  precede  the  appearance  of 
physical  signs  by  a  very  perceptible  interval  of  time,  even  five 
or  six  days,  during  which,  on  examining  the  chest,  no  dulness 
is  to  be  found.  The  breath-sounds  at  one  base  have,  how- 
ever, at  a  very  early  period  a  peculiar  rough,  harsh  quality, 
very  like  that  of  exaggerated  breathing.  A  few  hours  later 
the  characteristic  fine  hair  crepitation  may  be  abundantly 
evident,  whilst  the  percussion  note,  although  shortened  and 
heightened  in  pitch,  is  as  yet  by  no  means  dull.  In  other 
cases  the  physical  signs  of  complete  consolidation  may 
develope  so  rapidly  as  to  render  any  previous  stage  un- 
noticeable. 

Description  of  a  Case. — For  convenience  of  description  of 
the  general  aspect  and  physical  signs  of  pneumonia,  we  will 
commence  with  the  second  or  third  day  after  the  rigor,  the 
time  at  which  the  practitioner  is  most  commonly  called  upon 
to  see  such  a  case,  and  at  which  as  a  rule  there  is  not  much 
room  for  doubt  as  to  its  nature. 


PNEUMONIA  297 

The  flushed  look  and  burning  skin;  the  hurried,  noiseless 
breathing;  the  rapid  but  regular  pulse;  the  frequent  short 
cough,  half-stifled  from  pain;  the  dryish  thickly  coated  tongue; 
and  the  singular  prostration  of  the  patient  form  a  group  of 
signs  which,  supervening  speedily  upon  a  well-marked  fit  of 
shivering,  cannot  be  otherwise  interpreted  than  as  charac- 
teristic of  an  attack  of  ordinary  acute  basic  pneumonia  in  full 
intensity.  A  crop  of  herpes  will  often  be  observed  upon 
the  lip. 

On  closer  examination  the  respirations  are  found  to  number 
about  forty  in  the  minute.  They  are  not  obstructed,  but  are 
usually  attended  with  well-marked  action  of  the  nares.  The 
pulse  is  120,  the  temperature  104°  (Fig.  30).  On  inspecting  the 
chest,  its  movements  are  seen  to  be  chiefly  one-sided;  but  there 
is  no  apparent  difference  in  size  on  the  two  sides,  and  the  heart 
is  found  beating  in  its  normal  position.  The  movements  of  the 
affected  side  are  voluntarily  restrained  by  the  patient,  and  a 
severe  pain  referred  to  this  part  often  cuts  short  the  cough  or 
any  attempt  to  draw  a  full  breath.  The  percussion  signs  in 
front  are  not  materially  altered.  On  auscultation,  the 
respiratory  murmur  is  found  to  be  weaker  on  the  affected, 
exaggerated  on  the  healthy  side.  Posteriorly  over  the  base 
of  the  diseased  lung  the  percussion  note  is  dull,  but  not  without 
some  wooden  quality  of  tone  quite  distinct  from  the  dead  flat 
note  of  effusion.  The  dulness  extends  upwards  to  a  variable 
height,  and  over  the  dull  portion  the  vocal  fremitus  is 
increased,  the  respiration  is  characteristically  bronchial  or 
tubular,  the  voice-sounds  well  conducted  and  bronchophonic, 
whilst  the  peculiarly  explosive  fine  inspiratory  crepitation  of 
pneumonia  is  heard,  especially  towards  the  upper  limits  of 
dulness.  If  there  be  any  expectoration,  it  is  scanty,  viscid, 
frothy,  and  more  or  less  rust-coloured  from  blood-staining.  It 
contains  an  excess  of  chlorides,  and  is  deficient  in  phosphates. 
The  urine  is  scanty  and  concentrated,  and  as  in  certain  other 
febrile  states,  notably  typhus  and  typhoid  fever,  is  very 
deficient  in  chlorides,  owing  to  their  increased  retention  in  the 
body.^*  A  similar  condition  has  been  noted  in  acute  phthisis. 
In  about  half  the  cases  the  urine  yields  a  thin  cloud  of  albumin, 
and  in  a  small  percentage  definite  nephritis,  with  blood-casts, 
is  observed. 

The  blood  shows  peculiar  changes.     Its  clotting  power  is 


298 


DISEASES   OF   THE  LUNGS   AND   PLEim^ 


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PNEUMONIA  2gg 

increased,  and  the  amount  of  fibrin  formed  is  greater  than 
usual.  These  facts  were  well  known  to  the  older  writers,  who 
regarded  the  rapid  formation  of  a  firm  clot  after  bleeding 
as  of  good  prognostic  augury.  No  doubt,  too,  the  peculiar 
characters  of  the  pneumonic  exudation,  and  the  presence  of 
the  fibrin  network,  are  dependent  on  these  changes.  In  most 
cases  of  pneumonia  a  considerable  increase  in  the  number  of 
white  corpuscles  is  also  to  be  observed,  the  total  per  cubic 
millimetre  commonly  reaching  20,000,  and  sometimes  even 
50,000  or  more.  The  increase  begins  early  in  the  disease,  and 
gradually  becomes  more  marked,  until  with  the  crisis  the 
number  again  quickly  falls  to  normal,  although  not,  as  a 
rule,  quite  so  rapidly  as  tHe  temperature  (see  Fig.  30).  This 
leucocytosis,  as  we  shall  see,  possesses  some  diagnostic 
importance,  and  its  absence  in  an  undoubted  case  of  severe 
pneumonia  points  to  a  lack  of  reactive  power  on  the  part  of  the 
patient,  and  warrants  a  grave  prognosis.  In  many  cases,  as 
we  have  seen,  the  pneumococcus  may  be  detected  in  the  blood, 
and  from  the  observations  made  at  the  hospital  of  the  Rocke- 
feller Institute,  where  448  patients  were  examined,  it  would 
appear  that  this  occurs  chiefly  in  the  graver  cases  and  those 
with  a  higher  mortality.^"* 

To  follow  our  assumed  case  of  pneumonia  further  onwards ; 
the  temperature,  rising-  after  the  onset  with  rigor  to  104°, 
hovers  thereabouts,  with  but  little  variation  (unless  influenced 
by  treatment)  for  four,  five,  six,  or  seven  days,  and  occasionally 
longer,  and  then  rapidly  falls  within  thirty-six  hours  to  normal. 
This  abrupt  fall  of  temperature,  which  marks  the  crisis,  is  often 
attended  with  profuse  sweats,  a  copious  discharge  of  urine 
depositing  abundant  lithates,  and  more  rarely  with  diarrhoea. 
Some  exhaustion  is  always  present,  and  at  times  there  is 
decided  collapse.  After  this  brief  period  of  shock  has  passed, 
the  patient,  who  has  been  suffering  throughout  from  complete 
anorexia,  thirst,  restlessness,  and  increasing  weakness,  with 
dyspnoea,  troublesome  cough,  and  blood-stained  expectoration, 
is  rapidly  relieved  from  many  of  these  symptoms.  The  sense 
of  dyspnoea  is  greatly  lessened,  although  the  breathing  is  still 
accelerated.  The  pulse  becomes  quiet,  the  skin  moist,  and  the 
tongue  begins  to  clean  at  the  tip  and  edges.  Appetite  does  not 
yet  return,  but  sleep  is  quiet  and  refreshing.  Such  a  crisis 
occurs  in  about  sixty  per  cent,  of  all  cases ;  in  others  the  tem- 


300  DISEASES   OF   THE  LUNGS   AND   PLEURA 

perature  drops  more  slowly  by  lysis,  and  the  amelioration  of 
symptoms  is  correspondingly  more  gradual.  In  others,  again, 
the  crisis  is  overlapped  by  a  renewed  attack  on  the  opposite 
side,  with  its  attendant  return  of  fever. 

On  examination  after  the  fall  of  temperature  the  physical 
signs  will  be  found,  contrary  perhaps  to  expectation,  to  have 
but  little  changed.  Dulness  is  still  present,  and  bronchial 
breathing  and  bronchophony  are  as  distinct  as  ever.  Soon, 
however,  crepitant  sounds  somewhat  resembling  the  fine-hair 
crepitation  heard  at  the  commencement  of  the  disease,  again 
make  their  appearance.  These  are,  however,  larger,  moister, 
less  explosive,  and  are  heard  during  expiration  as  well  as 
inspiration,  although  still  most  abundantly  with  inspiration. 
This  subcrepitant  rale,  or  redux  crepitation,  as  it  is  termed, 
marks  the  commencing  resolution  of  the  hepatised  lung,  and 
extends  downwards  as  the  consolidation  slowly  melts  away. 
The  sputum,  usually  still  scanty,  now  becomes  more  opaque; 
in  certain  cases  it  is  muco-purulent  and  amounts  to  several 
ounces  during  the  day.  In  no  case  is  lung  tissue  to  be  dis- 
covered in  it.  Sometimes  even  in  the  adult,  and  often  in 
children,  there  is  from  first  to  last  no  expectoration  in  pneu- 
monia. 

After  the  period  of  crisis  there  is  in  some  cases  a  slight 
return  of  fever  for  a  few  days,  but  of  a  character  different  from 
that  of  the  original  disease.  The  temperature  assumes  a  hectic 
type,  with  a  moderate  daily  rise  to  loi"  or  even  102°,  and  in 
these  cases  slight  daily  chills  may  be  experienced.  These 
symptoms  are  somewhat  alarming,  and  suggest  the  possibiHty 
of  some  complication.  But  they  do  not  necessarily  bear  this 
interpretation,  for  we  have  observed  them  in  several  cases  in 
which  recovery  has  been  otherwise  uneventful.  The  explana- 
tion is  possibly  to  be  found  in  the  too  rapid  absorption  of 
inflam.matory  products,  the  toxic  quality  of  which  has  not  as 
yet  been  entirely  neutralised.^^ 

Diagnosis. — In  a  characteristic  case  of  acute  lobar  pneu- 
monia the  diagnosis  is  not  as  a  rule  difficult.  The  sudden  onset, 
the  character  of  the  temperature  chart,  the  hurried  breathing, 
with  working  alae  nasi,  should  at  once  suggest  the  disease. 
Later  the  rusty  sputum  and  development  of  physical  signs 
render  the  case  clear. 

But  in  other  instances,  as  in  the  septic  variety,  which  we  shall 


PNEUMONIA  301 

presently  describe,  the  localising  signs  are  less  definite,  and  for 
a  time  it  may  be  diffictdt  to  decide  between  typhoid  fever  and 
pneumonia.  In  such  circumstances  the  blood  should  be 
examined,  a  definite  leucocytosis,  if  found,  speaking  strongly 
in  favour  of  pneumonia,  a  positive  Widal  reaction,  on  the  other 
hand,  deciding-  in  favour  of  typhoid  fever. 

In  other  cases  the  diagnosis  from  pleural  effusion  is  not 
altogether  easy.  Thus  we  have  observed  more  than  once  well- 
marked  examples  of  dense  consolidation,  involving  the  whole 
lung,  in  which  breath-sounds  were  inaudible  and  vocal  fremitus 
correspondingly  diminished.  The  diagnosis  of  pneumonia 
was  arrived  at  principally  from  the  very  slight  cardiac  dis- 
placement, which  would  have  been  far  more  extensive  had  the 
condition  been  an  effusion  into  the  pleura.  In  the  cases 
referred  to,  redux  crepitation  subsequently  developed  and  the 
consolidation  cleared  up.  Doubtless  the  absence  of  breath- 
sounds  was  due  to  an  unusually  large  overflow  of  coagulating 
exudation  into  the  smaller  bronchi.  Similar  cases  have  been 
recorded  by  other  observers,^^  in  which  at  the  autopsy  this 
explanation  has  proved  to  be  correct.  Again,  as  we  have 
pointed  out  in  dealing  with  pleurisy,  loud  bronchial  breathing 
mav  be  sometimes  heard  over  an  effusion,  and  suggests  con- 
solidation of  the  lung.  Here,  also,  evidence  of  displacement  or 
otherwise  of  the  heart  is  of  great  importance,  and  should 
indicate  a  right  diagnosis.  In  any  case  in  which  there  is  real 
doubt  the  exploring  syringe  should  be  used. 

But  beyond  the  diagnosis  of  inflammation  of  the  lung,  we 
have  further  to  look,  in  view  of  treatment  and  prognosis,  to 
the  conditions  which  have  led  up  to,  caused,  or  which  compli- 
cate the  attack.  Has  the  disease  supervened  upon  shock  or 
exhaustion,  alcoholism  or  uraemia?  Is  it  the  result  of  some 
poison  influence  or  sewer-gas  emanation,  to  which,  it  may  be, 
the  patient  is  still  exposed  ?  Has  exposure  to  severe  chill  or 
direct  cold  resulted  in  inflammatory  congestion  or  consolida- 
tion in  a  strong,  full-blooded,  or  a  delicate  person?  The 
questions  thus  formulated  can  only  be  answered  by  separate 
inquiries  in  each  case,  but  they  are  of  even  more  importance 
than  a  merely  physical  diagnosis. 


302  DISEASES   OF  THE  LUNGS   AND  PLEURA 

Varieties  of  Pneumonia. 

The  following  varieties  of  pneumonia,  which  differ  some- 
what from  the  ordinary  type,  may  now  be  described. 

Septic  Pneumonia. — This  variety,  formerly  spoken  of  as 
typho-  or  pytho genie  pnemnonia,*  is  marked  by  a  less  sudden 
onset,  greater  prostration,  a  more  prolonged  course,  and 
by  less  pronounced  pulmonary  symptoms  than  are  usually 
observed.  It,  therefore,  not  uncommonly  suggests  typhoid 
fever.  The  following  is  a  fairly  typical  example  of  this  form 
of  the  disease : 

Minnie  L.,  aged  nineteen,  a  nursemaid  living  in  London,  a  light- 
haired,  well-nourished  girl,  was  admitted  into  the  Middlesex  Hos- 
pital, under  Dr.  Douglas  Powell,  on  November  27,  1882.  She  had  a 
family  history  of  chest  delicacy,  but  had  herself  suffered  from  no 
previous  illnesses.  Several  persons  in  the  house  where  she  resided 
were  stated  to  have  complained  recently  of  feverish  and  abdominal 
symptoms,  and  the  water  of  which  the  patient  had  drunk  freely  was 
regarded  with  suspicion,  and  directions  had  been  given  that  it  should 
be  boiled  before  being  used  for  drinking  purposes. 

The  patient  had  returned  to  town  from  Folkestone  at  the  end  of 
October,  and  had  been  in  her  usual  health,  except  for  slight  head- 
ache during  a  fortnight,  until  November  23,  when  she  was  taken 
ill  with  shivering,  frontal  headache,  pains  in  the  back  and  limbs, 
giddiness,  nausea,  and  cough,  without  expectoration.  The  shivering 
was  repeated  several  times  during  the  interval  between  the  date  of 
her  attack  and  her  admission  to  the  hospital,  the  fourth  day  of  ill- 
ness. The  skin  was  then  found  to  be  hot  and  dry,  the  lips  parched 
and  cracked,  the  tongue  coated,  and  the  bowels  confined.  No  physical 
signs  could  be  discovered  except  some  enlargement  of  the  spleen.  On 
the  eighth  day  imperfect  dulness  and  patchy  crepitations  were  ob- 
served at  the  left  base,  with  bronchial  breathing.  On  the  tenth  day 
some  tubular  breath-sound  was  also  heard  at  the  left  subclavicular 
region.  On  the  thirteenth  day  there  was  patchy  dulness  and  crepita- 
tion over  the  left  back  and  front  of  the  chest,  exaggerated  breathing 
in  the  right  subclavicular  region,  and  scattered  crepitation  over  the 
right  axillary  region  and  posterior  base ;  rusty  sputa ;  delirium. 

On  the  fourteenth  day  the  note  was  as  follows  :  Right  side :  Con- 
siderable resonance  of  tubular  quality  over  tenth  and  eleventh  ribs 
posteriorly,  with  dulness  above,  including  the  region  of  the  scapula. 
Coarse  rales  at  the  extreme  base ;  inspiratory  crepitation  over  scapula. 
In  front  exaggerated  respiration ;  in  lower  axilla  subcrepitant  rales. 

*  The  term  "  pythogenic "  was  originally  suggested  by  the  late  Dr. 
Charles  Murchison"  for  Typhoid  Fever,  and  was  first  applied  to  pneumonia 
by  Drs.  Grimshaw  and  Moore." 


PNEUMONIA 


303 


Left  side:  Posteriorly,  patchy  dulness,  with  coarse  scattered  liquid 
rales.  Anteriorly,  dulness  in  subclavicular  region,  with  moist  rales 
and  some  larger  clicks.  One  doubtful  spot  suggestive  of  typhoid 
fever  was  observed  on  the  abdomen.  Death  occurred  on  the  morn- 
ing of  the  sixteenth  day.  The  appended  chart  (Fig.  31)  gives  the 
temperature  of  this  case,  and  illustrates  fairly  well  the  more  pro- 
longed and  fluctuating  course  of  the  fever  which  differentiates  typical 
cases  of  this  variety  from  those  of  the  more  ordinary  form  of  pneu- 
monia. 


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Fig.  31. — Chart  showing  the  Temperature  Record  of  M.  L.,  aged 
Nineteen,  who  suffered  from  Septic  Pneumonia. 

B=cool  bath;    Q  =  quinine   (10   grains);    *  =  salicylate   of   soda    (20   grains 

every   four   hours). 


Post-Mortem :  no  lesions  of  typhoid  fever  were  found. 

The  upper  lobe  of  the  right  lung  was  solid,  except  at  its  extreme 
apex  and  along  the  anterior  edge.  On  section,  the  general  appear- 
ance was  that  of  red  hepatisation,  the  central  portions  being  of  a 
lighter  colour  than  the  rest,  and  inclining  to  grey.  Several  dark 
wedge-shaped  patches  were  also  seen  (recent  haemorrhagic  infarcts)  in 
the  neighbourhood  of  which  the  vessels  were  found  thrombosed. 

Right  middle  lobe :  soft  and  crepitant. 

Right  loxver  lobe :  quite  solid,  in  appearance  resembling  the  upper, 
and  containing  also  some  infarcts. 


304  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Left  upper  lobe :  rather  dark  in  colour,  showing  consolidation  with 
considerable  oedema  and  some  infarcts. 

Left  lower  lobe:  fairly  crepitant,  except  for  a  patch  of  consolida- 
tion at  its  upper  and  one  at  its  lower  edge. 

Heart :  ante-  and  post-mortem  coagula  in  cavities  of  both  sides. 
Muscular  tissue  firm. 

The  diagnosis  was  in  this  case  at  first  very  uncertain,  and  even 
when  pulmonary  signs  made  their  appearance  they  were  of  that 
scattered  description  not  incompatible  with  their  being  a  part  of 
the  manifestations  of  typhoid  fever.  The  enlargement  of  the  spleen, 
again,  pointed  in  the  same  direction ;  and,  although  there  were,  with 
one  doubtful  exception,  no  spots  present,  one  or  two  relaxed  pale 
motions  were  passed.  At  the  date  at  which  the  case  was  observed 
neither  the  leucocytosis  nor  the  agglutination  test  was  known,  but 
the  extent  of  the  pulmonary  lesions  led  to  the  diagnosis  of  septic 
pneumonia,  which  proved  correct. 

Migratory,  Creeping,  or  Wandering  Pneumonia. — This 
variety,  which  has  been  well  described  by  the  late  Professor 
Dreschfeld,"  probably  does  not  differ  essentially  from  the 
septic  variety,  of  which  the  case  just  related  is  an  example. 
Here  again  we  have  a  more  insidious  onset,  a  more  fluctuating 
type  of  temperature,  and  an  incomplete  crisis  or  termination 
(when  not  fatal)  by  lysis.  The  physical  signs  show  a  consolida- 
tion involving  successive  contiguous  portions  of  one  lung,  and 
then  extending  to  the  other  in  the  same  manner,  or  in  other 
cases  attacking  different  portions  of  the  lungs.  Bronchitis  as 
a  marked  feature  is  absent.  The  illness  is  of  an  asthenic  type, 
less  sporadic,  and  more  liable  to  attack  families  and  groups  of 
people  under  certain  unhygienic  conditions.  Dr.  Dreschfeld 
found  in  his  fatal  cases  that  sections  of  portions  of  the  lung- 
more  recently  attacked  teemed  with  encapsuled  diplococci, 
some  situated  in  the  exudation  within  the  alveoli,  others 
occupying  the  interstitial  tissues.  Although  more  numerous 
than  in  ordinary  pneumonia,  they  were  not  otherwise  dis- 
tinctive. 

Latent  Pneumonia. — Cases  are  sometimes  met  with  in 
hospital  and  private  practice,  but  mostly  in  the  former,  in 
which,  with  characteristic  rise  of  temperature  and  symptoms 
suggestive  of  pneumonia,  often  including  rusty  sputum,  there 
are  yet  from  first  to  last  no  physical  signs  which  would  warrant 
a  diagnosis  of  this  disease.  In  such  cases  there  is  probably 
some  deep  central  patch  of  consolidation.    In  other  instances 


PNEUMONIA  305 

the  symptoms  are  but  slightly  marked,  so  far  as  they  point  to 
chest  disease,  and  only  at  the  autopsy  is  the  pneumonia  dis- 
covered. Cases  of  this  type  not  uncommonly  arise  at  the  closet 
of  malignant  or  surgical  maladies. 

Influenzal  Pneumonia. — This  variety  of  the  malady,  with 
which,  owing  to  the  recent  epidemics,  we  are  now  unhappily 
so  familiar,  is  essentially  of  the  nature  of  a  broncho-pneu- 
monia, and  will  be  considered  in  the  succeeding  chapter 
(see  p.  331). 

Unusual  Terminations  of  Pneumonia. — Although  as  a  rule 
the  consolidation  of  pneumonia  clears  up  with  fair  uniformity 
in  the  inverse  order  of  its  formation,  it  certainly  does  not  do  so 
in  all  cases,  and  detached  islets  of  resolving  exudation  some- 
times give  rise  to  physical  signs — largish  clicks  and  circum- 
scribed blowing  sounds — which  it  may  be  almost  irnpossible  to 
distinguish  from  those  of  pulmonary  disintegration,  A  careful 
examination  of  the  sputa  for  elastic  tissue  and  tubercle  bacilli 
is  then  essential. 

In  other  patients  resolution  may  proceed  very  slowly,  and 
the  lung  remains  for  some  weeks,  or  even  months,  in  a  con- 
dition of  consolidation.  Such  delayed  resolution  is  most  apt  to 
occur  in  alcoholic  subjects,  and  may  eventually  clear  up.  In 
many  cases,  however,  the  lung  is  left  somewhat  thickened  and 
oedematous,  giving  rise  to  those  permanent  crepitations  wdiich 
are  heard  over  the  base  of  one  lung  in  certain  elderly  persons. 
In  exceptional  instances  fibrosis  of  the  lung  tissue,  leading 
later  to  bronchiectasis,  takes  place. 

Another  termination  of  the  pulmonary  disease  sometimes 
met  with  in  pneumonia  is  diffuse  suppuration,  or  purulent  in- 
filtration, of  the  lung  (see  p.  295).  The  symptoms  which  attend 
this  fatal  change  are  of  a  typhoid  type :  the  fever  continues 
and  shows  a  fluctuating  range ;  the  tong'ue  becomes  dry,  brown 
and  tremulous;  the  prostration  is  marked  and  attended  with 
muttering  delirium;  rig"ors,  sweating,  and  sudamina  may  be 
present.  The  redux  crepitations  normal  to  the  period  of 
disease  are  replaced  by  coarse  liquid  rales;  the  respirations 
become  increasingly  rapid^  and  attended  with  laryngeal  rattle, 
and  the  pulse  rapid  and  compressible.  Death  soon  terminates 
the  scene. 

Abscess  or  circumscribed  suppuration  of  the  lung  is 
occasionally   met  with.     The  purulent  collection  is   usually, 

20 


306  DISEASES   OF  THE  LUNGS   AND   PLEURA 

although  not  necessarily,  a  small  one ;  the  walls  are  generally- 
soft,  and  the  surrounding  lung  tissue  in  a  condition  of  dis- 
integration. In  other  cases  several  small  foci  of  suppuration 
are  present.  The  condition,  like  that  of  purulent  infiltration,  is 
generally  due  to  secondary  invasion  of  the  lung  by  the 
pyogenic  cocci,  but  may  result  from  the  unaided  action  of  the 
pneumococcus. 

The  symptoms  attending  the  formation  of  an  abscess  are 
sometimes  slight,  but  continued  pyrexia  and  rigors,  followed 
by  sweatings,  towards  the  latter  period  of  the  disease  would 
suggest  suppuration.  But  it  not  infrequently  happens  that  the 
first  sign  which  enables  us  to  recognise  this  complication  is 
the  discharge  of  the  abcess  through  the  bronchus,  and  the 
sudden  expectoration  of  a  large  quantity  of  pus,  which  may  be 
very  foetid  and  amongst  which  irregular  fragments  of  lung 
tissue  and  elastic  fibres  are  to  be  found.  This  having  occurred, 
cavernous  breath-sound  and  gurgling  rales  will  be  heard  over 
a  portion  of  the  consolidation  where  the  breath-sounds  were 
perhaps  before  suppressed.  Recovery  from  this  complication 
may  take  place,  but  the  outlook  is  always  serious.  For  a 
further  consideration  of  the  subject  we  must  refer  the  reader 
to  Chapter  XXII. 

Gangrene  of  the  Lung  is  also  a  condition  which  from  time 
to  time  presents  itself  in  the  later  stages  of  pneumonia  in 
cachectic  subjects,  and  particularly  in  the  intemperate.  It  is 
more  frequently  met  with  in  apex  pneumonia  in  the  adult.  The 
symptom  which  characterises  the  onset  of  gangrene  is  foetor 
of  breath,  and  there  may  be  no  other  sign  of  the  complication, 
for  the  sphacelus  need  not  be  large,  and  until  it  has  been 
evacuated  no  appreciable  cavity  may  exist.  The  disintegration 
of  the  sphacelus  is  attended  with  darkened  foetid  sputa,  which 
on  microscopical  examination  will  sometimes  be  found  to 
contain  fragments  of  lung  tissue  and  elastic  fibres,  not, 
however,  so  frequently  as  might  be  anticipated,  for  reasons 
which  we  have  already  given  (p.  73).  Gangrene  is  a  very  grave 
complication,  though  not  necessarily  fatal. 

Implication  of  Other  Organs.— In  the  majority  of  cases  com- 
plications affecting  other  organs  are  produced,  as  we  have  seen, 
by  the  dissemination  of  the  pneumococcus,  which  may  reach 
its  destination  either  by  the  lymph  tracts,  as  in  empyema,  or 
through  the  blood,  as  in  meningitis,  endocarditis,  or  arthritis, 


PNEUMONIA 


2>o7 


In  rare  instances  they  are  produced  by  the  ordinary  pyogenic 
organisms. 

If  we  examine  the  statistics  from  the  various  London 
hospitals,  brought  forward  in  the  discussion  upon  "  Pneumonia 
and  its  Comphcations"  at  the  Royal  Society  of  Medicine, 
introduced  by  Dr.  Hector  MacKenzie,^"  we  find  that  such 
complications  are  in  reality  uncommon.  The  incidence  of  the 
more  important  of  them  is  shown  in  the  following  table,  which 
we  have  compiled  from  the  London  statistics  above  referred 
to,  and  which  relate  to  7,394  cases  of  the  disease,  of  which 
1,592  cases  died,  giving  a  total  death-rate  of  2V^i. 

Table  showing  the  Frequency  and  Mortality  of  the  More  Important 
Complications  of  Pneumonia,  based  upon  the  Recent  Experience 
OF  THE  Chief  London  Hospitals. 


Complications. 

r 
Frequency  of  Occurrence 
among  7,394  Cases. 

Mortality  among  the  7,394  Cases. 

Actual. 

Per  Cent. 

Actual. 

Per  Cent,  of 

Total  Per> 

those  affected. 

centage. 

Empyema      

258 

3-48 

83 

32-17 

1-12 

Pleurisy,  with  serous 

effusion      

114 

I '54 

13 

11-40 

0-17 

Pericarditis 

243 

3-28 

172 

70-78 

2-32 

Endocarditis 

62 

0-83 

54 

87-09 

073 

Meningitis     

23 

0-31 

22 

95 '65 

0-29 

Peritonitis      

23 

0-31 

16 

69-56 

0-21 

Gangrene  of  lung     ... 

31 

o"4i 

26 

83-87 

0-35 

Abscess  of  lung 

24 

0*32 

19 

79-16 

0-25 

Arthritis         

29 

0-39 

5 

17-24 

0-06 

Otitis  media 

25 

o"33 

4 

16-00 

0-05 

Venous  thrombosis  . . . 

28 

o'37 

4 

14-28 

0-05 

Colitis             

14 

o-i8 

7 

50-00 

0-09 

Parotitis         

4 

o'05 

I 

25-00 

0-0 1 

Peripheral  neuritis  ... 

4 

o'o5 

I 

25-00 

o-oi 

Of  the  above  complications  pleurisy  is  a  more  or  less 
essential  concomitant  of  pneumonia.  When  pronounced, 
however,  it  forms  a  serious  comphcation  of  the  disease,  the 
suffering  which  it  entails  adding  greatly  to  the  exhaustion 
of  the  patient.  Moreover,  in  cases  in  which  the  pleura  is  so 
decidedly  involved  the  temperature  does  not  as  a  rule  subside 
with  the  abruptness  typical  of  pneumonia.  In  some  cases  an 
effusion  forms,  either  of  the  sero-fibrinous  or  purulent  variety. 
In  the  case  of  a  serous  effusion,  which  is  less  common,  the 
liquid  is  as  a  rule  soon  reabsorbed.  The  purulent  variety 
(empyema)    is    generally   heralded   by    a    secondary   rise    of 


308  DISEASES   OF   THE  LUNGS   AND   PLEURA 

temperature  after  the  critical  fall :  the  pus  must  be  evacuated 
without  delay,  and  if  this  be  done,  the  prognosis  in  the  majority 
of  cases  is  favourable.  Of  the  258  cases  in  the  above  table, 
recovery  took  place  in  175,  or  68  per  cent. 

Almost  as  often  as  empyema  do  we  meet  with  pericarditis 
as  a  complication  of  pneumonia,  and  statistics  show  that  it  is 
a  very  serious  one.  The  danger  must  not,  however,  be 
exaggerated,  for  the  inflammation  may  be  limited  to  a 
fibrinous  patch,  which  is  discovered  unexpectedly  by  hearing 
the  friction  sound  during  the  daily  examination  of  the  patient, 
and  under  suitable  treatment  the  condition  sometimes  clears 
up  quickly.  If  extensive,  the  complication  is  an  index  of  a 
grave  variety  of  pneumonia,  and  the  case  often  terminates 
fatally. 

A  purulent  effusion,  or  pyopericardium,  may  develope. 
This  dangerous  complication,  much  more  rare  than  the  corre- 
sponding affection  of  the  pleura,  generally  occurs  somewhat 
late  in  the  disease,  and  is  not  necessarily  preceded  by  any 
friction  sound,  or  accompanied  by  fever.  Thus  we  have 
known  it  to  arise  after  pneumonia  in  an  abstemious  and 
previously  healthy  man  of  twenty-four,  and  to"  be  indicated 
only  by  a  gradually  enlarging  area  of  cardiac  dulness  and  an 
increasing  irregularity  and  feebleness  of  the  pulse.  The 
temperature,  which  in  this  case  had  fallen  to  normal  on  the 
fourteenth  day,  did  not,  during  the  development  of  the  cardiac 
symptoms,  rise  above  99°  up  to  the  time  of  the  patient's  death, 
nineteen  days  later.  Indeed,  so  slight  were  the  signs  and 
so  gradual  the  increase  in  cardiac  dulness,  that  the  case  was 
regarded  during  life  as  one  of  dilatation  of  the  heart,  and  it 
was  not  until  after  death,  when  the  pericardium  was  found  to 
be  full  of  pus,  that  the  true  nature  of  the  lesion  was  revealed. 

Endocarditis  of  the  mahgnant  type  is  a  rarer  but  more 
dangerous  complication  than  pericarditis.  In  some  cases  it 
manifests  itself  by  a  return  of  fever  some  little  time  after  the 
temperature  has  become  normal,  by  sweatings,  rigors,  and- by 
the  development  of  cardiac  murmurs  and  symptoms;  but 
more  often  the  objective  signs  are  obscure.  It  attacks  chiefly 
the  left  side  of  the  heart,  and  the  aortic  valves  more  frequently 
than  the  mitral,  and  is  more  apt  to  occur  when  an  old  endo- 
cardial lesion  is  present. 

Meningitis  may  occur  either  during  the  course  of  the  pneu- 


PNEUMONIA  309 

monia  itself  or  very  shortly  after  the  crisis,  when  a  secondary 
rise  of  temperature,  with  meningeal  symptoms,  indicates  its 
presence.  It  is  a  rare  complication,  nearly  always  produced 
by  the  pneumococcus,  and  is  speedily  fatal. 

Among  other  complications  sometimes  met  with,  may  be 
mentioned  suppurative  peritonitis,  which  is  always  of  grave 
augury.  Of  more  favourable  outlook  are  arthritis^  which 
affects  especially  the  knee  and  shoulder,  and  otitis  media. 
Both  are  purulent  in  nature,  and  sometimes,  but  not  always, 
the  result  of  pneumococcic  infection.  Suppurative  parotitis, 
on  the  other  hand,  is  more  often  produced  by  the  staphy- 
lococcus aureus. 

Venous  thrombosis,  colitis,  and  peripheral  neuritis  are  com- 
plications also  met  with  from  time  to  time. 

Prognosis. — Each  year  more  than  20,000  persons  die  in 
England  and  Wales  from  pneumonia,  a  mortality  sufficiently 
great  to  place  the  disease  in  the  front  rank  of  those  dangerous 
to  life.  Advanced  age  and  alcoholism  are  the  most  important 
states  unfavourable  to  recovery.  Pre-existing  chronic  diseases, 
such  as  Bright's  disease  or  diabetes,  are  likewise  very  un- 
favourable elements  in  prognosis.  It  is  also  a  relatively  fatal 
malady  in  those  whose  nervous  systems  have  been  exhausted 
by  previous  mental  anxiety  or  overstrain. 

The  severity  of  attacks  varies  much  in  individual  cases,  and 
in  the  pneumonias  prevalent  in  different  years.  At  St.  Bar- 
tholomew's Hospital,  in  the  ten  years  1906  to  191 5,  there  were 
admitted  2,113  cases,  with  255  deaths,  a  death-rate  of  12  per 
cent.,  the  mortality  varying  in  the  different  years  from  8-6  to 
14-9  per  cent.  But  above  this  percentage  of  fatal  cases  there 
is  a  highly  fluctuating  margin  in  which  elevation  or  depres- 
sion of  the  death-rate  is  greatly  dependent  upon  treatment. 
In  each  case  the  extent  and  character  of  the  disease  must  be 
taken  into  account.  It  will  be  obvious  that  double  pneumonia 
is  much  more  serious  than  single.  The  prognosis  is  also 
more  grave  in  the  septic  forms  which  we  have  described,  but 
such  cases  differ  greatly  among  themselves,  and  we  have  no 
statistics  by  which  their  mortality  can  be  exactly  compared 
with  that  of  ordinary  pneumonia.  The  danger  in  these  cases 
arises  more  from  the  general  state  than  from  the  extent  of 
lung  involved.  In  children  pneumonia  generally  runs  a 
favourable  course,  and  the  consoHdation  melts  away  some- 


3IO  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

times  with  astonishing  rapidity.  Apex  pneumonia  is  a  some- 
what more  dangerous  variety  than  the  basic  form  in  that  it  is 
more  prevalent  amongst  alcoholic  and  cachectic  subjects. 

Herpes,  especially  on  the  lips,  is  a  not  uncommon  accom- 
paniment of  pneumonia.  Geissler"  observed  it  in  182,  or  43-2 
per  cent.,  of  his  421  cases,  and  showed  that  the  mortality  was 
considerably  less  among  those  in  whom  the  complication 
occurred.     This  observation  agrees  with  our  own  experience. 

A  temperature  above  105°,  a  pulse  over  120,  and  respira- 
tions over  40,  are  significant  of  a  serious  case.  Delirium  is 
always  a  grave  symptom,  and  in  intemperate  subjects  delirium 
tremens  is  apt  to  occur,  especially,  perhaps,  in  the  apical 
variety  of  the  disease. 

A  brick-dust  rustiness  of  sputa  is  the  usual  degree  of  san- 
guineous tinge  in  the  first  days  of  the  disease.  A  darker  and 
more  prune-juice  colour  is,  however,  sometimes  observed  in 
old  people,  and  in  them  it  is  not  necessarily  of  unfavourable 
augury.  Decided  haemoptysis  is  rare  in  pneumonia,  and  was 
regarded  by  Walshe  as  significant  of  tubercle.  We  have, 
however,  seen  several  examples  in  which  rather  sharp 
haemopytsis  has  occurred,  and  in  which  the  disease  never- 
theless ran  a  favourable  course,  without  any  evidence  of 
tuberculous  infection.  The  absence  of  any  colouration  of 
sputa  in  otherwise  well-marked  pneumonia  would  lead  us 
from  experience  to  fear  a  tardy  or  incomplete  convalescence. 

Treatment. — Before  speaking  of  treatment,  it  is  important 
again  to  observe  that  pneumonia  varies  greatly  with  regard 
to  severity  and  type  in  different  epidemics,  and  that  the 
subjects  are  individuals  varying,  perhaps  even  more  widely, 
in  constitution  and  powers  of  resistance.  Hence,  while  there 
may  be  a  general  plan  of  treatment  best  adapted  to  steer  the 
patient  through  the  dangers  of  this  disease,  there  is  room  for 
much  diversity  in  detail,  and  no  one  system  of  treatment  can 
be  accepted  for  all  cases.  Before  all  things  it  must  be  re- 
membered that  the  physician  has  to  deal  with  a  general 
disease,  a  specific  infection,  as  well  as  with  a  local  expression 
of  that  disease,  the  inflammatory  condition  in  the  lungs. 

The  difiticulties  and  dangers  which  arise  are  grouped  about 
the  four  consecutive  periods  of  the  malady — those  of  hyper- 
cEinia,  consolidation,  crisis,  and  resolution. 

Absolute  confinement  to  bed  in  a  good  well-ventilated  room 


PNEUMONIA  3 1 1 

of  moderate  temperature,  and  the  attendance  of  a  careful, 
obedient  nurse,  are  of  the  first  importance  in  the  treatment  of 
all  cases  of  pneumonia. 

I.  Stage  of  Hypercemia.— In  the  first  stage  of  the  disease 
(a)  shock,  (b)  pyrexia,  (c)  pulmonary  congestion,  and  (d)  pain 
are  the  indications  which  direct  our  treatment. 

The  shock  at  the  commencement  of  the  disease,  immedi- 
ately after  the  rigor,  is  often  considerable,  especially  in  old 
people  and  youngs  children,  although  it  is  rarely  so  marked 
as  in  certain  cases  of  acute  bronchitis.  Alcoholic  stimulants 
may  be  needed  at  this  period,  but  quietude  in  bed  and  nutri- 
tious soup  are  the  best  restoratives.  A  few  doses  of  bromide 
with  aromatic  ammonia  may  be  required. 

In  this  pyrexial  stage  of  pneumonia  the  bowels  should  be 
well  cleared  by  a  few  grains  of  calomel  and  a  saline  aperient, 
after  which  a  mixture  containing  liquor  ammonii  acetatis  and 
citrate  of  potash  should  be  prescribed.  In  this  way  blood- 
pressure  is  relieved,  and  pulmonary  congestion  lessened  by 
natural  elimination  from  the  skin,  kidneys  and  bowels,  instead 
of  by  emptying  the  arterial  into  the  venous  system,  as  is 
effected  by  drugs  of  the  aconite  class  when  given  in  sufficient 
doses.  These  latter  remedies  were  fashionable  twenty  years 
ago,  but  as  the  favourable  issue  of  the  disease  commonly  turns 
upon  the  maintenance  of  heart  power  and  vessel  tonicity,  and 
since  both  are  lowered  by  aconite  and  its  allies  at  the  very 
outset — sometimes,  indeed,  beyond  recall — their  administra- 
tion cannot  be  recommended. 

The  pyrexia  of  pneumonia  is  of  brief  duration,  and,  it  must 
never  be  forgotten,  is  normal  to  the  disease.  If,  therefore, 
the  temperature,  which  should  in  all  cases  be  carefully  watched 
and  recorded,  does  not  mount  above  104°,  it  requires  no 
energetic  interference  at  this  stage.  Sponging  with  tepid 
water,  to  which  a  little  sal-volatile  or  Rimmel's  toilet  vinegar 
has  been  added,  will  slightly  moderate  it,  and  be  comforting 
to  the  patient.  Cool  drinks  and  saline  medicines  will  be 
similarly  useful.  In  children,  who  can  be  lifted  about  with 
ease,  the  temperature  may  be  kept  under  by  the  warm  bath 
at  90°  employed  as  often  as  may  be  necessary,  with  small 
doses  of  quinine.  In  adults  this  measure  is  in  private  practice 
more  difficult  and  disturbing  to  carry  out.  It  may  be  replaced 
by  "cradling" — that  is  to  say,  lifting  the  sheet  from  off  the 


"312  DISEASES    OF  THE  LUNGS   AND   PLEURA 

patient  on  to  a  cradle  placed  over  the  bed,  and,  if  necessary, 
suspending  from  its  central  rib  india-rubber  bags  containing 
ice  ("  ice-cradling  ").  If  the  temperature  reach  105°,  a  powder 
or  cachet  containing  2\  grains  of  quinine  and  5  or  7  grains 
of  aspirin,  four  or  six  times  in  the  twenty-four  hours,  should 
be  given  to  the  adult.  In  some  cases,  where  the  pyrexia  is 
high,  and  bearing  in  mind  its  real  origin  in  bacterial  toxaemia, 
quinine  may  be  given  per  rectum  in  5  or  10  grain  doses  in 
the  form  of  suppository  made  with  coca-butter,  morning  and 
evening,  supplementai-y  to  or  in  replacement  of  that  taken 
in  the  mixture. 

Should  the  temperature  rapidly  rise  in  spite  of  the  remedial 
measures  above  suggested,  the  cold  pack  or  the  cool  bath — • 
i.e.,  at  80°  or  70° — must  be  employed.  Ice-bags  to  the  head 
are  useful  for  adults  in  aid  of  antipyretic  measures. 

The  pain  of  pneumonia,  which  indicates  the  seat  of  lesion 
and  aggravates  dyspnoea,  should  be  treated  by  local  rather 
than  general  measures.     Opium  or  the  subcutaneous  use  of 
morphia  may  be   necessary  in    exceptional   cases,   but   they 
are  not  desirable  means  of  combating  this  symptom.     Hot 
poultices  frequently  renewed,  due  care  being  taken  to  apply 
them  with  as  little  disturbance  of  the  patient  as  possible,*  are, 
on  the  contrary,  valuable  remedies  in  relieving  pain  by  lessen- 
ing vascular  tension  in  the  pleura.     This  they  effect  by  dilating 
the  superficial  capillaries  of  the  intercostal  vessels  concerned. 
Antiphlogistine  is  a  convenient  substitute  for  poultices,  especi- 
ally where  skilled  nursing  is  not  available,  since  an  appHcation 
of  the  antiphlogistine  paste,  covered  with  a  layer  of  warm 
cotton-wool,  can  be   left  applied  for  twelve  hours  without 
further  disturbance  of  the  patient,  giving  support  and  having 
a  decided  stimulating  effect.     When  the  pain  is  severe,  from 
four  to  a  dozen  leeches  may  be  employed  with  great  relief, 
and  it  is  sometimes  well  to  encourage  the  bleeding  by  the 
immediate  renewal  of  poultices  or  fomentations.     The  condi- 
tion of  the  patient,  and  especially  the  evidence  of  any  venous 
plethora,  as  indicated  by  lividity,  and  hardness  of  pulse,  will 
guide  us  with  regard  to  the  number  of  leeches.     In  country 
or  colonial  practice  cases  may  very  possibly  be  met  with  in 
which  a  venesection  to  eight  or  twelve  ounces  may  be  useful 
at  the  first  onset  of  pneumonia.     In  cases  of  severe  pain, 

*  See  direction  under  this  heading  in  chapter  on  Bronchitis,  p.   i88. 


PNEUMONIA  373 

where  leeches  are  not  desirable,  a  blister  of  three  or  four 
inches  square,  applied  under  the  poultice,  is  often  valuable. 
Cold  applications  are  recommended  by  many  physicians;  we 
cannot  say  that  we  have  been  at  all  impressed  with  their  utility, 
except  in  cases  in  which  the  fever  is  excessive  or  prolonged, 
when  they  are  useful  in  relieving  pain  and  reducing  pyrexia. 

The  diet  of  the  patient  must  consist  of  nutritious  fluids, 
milk,  strong  beef-tea,  mutton  or  chicken  broth,  with  perhaps 
some  farinaceous  thickening.  The  milk  may  be  diluted  with 
effervescing  water  or  flavoured  with  tea  or  coffee.  Cream  is 
sometimes  a  useful  addition  to  the  dietary.  The  food  and 
stimulants  should  be  given  at  intervals  of  about  two  hom-s, 
and  in  reasonable  quantities,  adapted  to  the  exigences  of  the 
case.  It  has  occurred  to  us  not  infrequently  to  see  a  patient 
overdone  with  food,  his  circulation  overloaded,  and  the 
abdomen  distended  from  the  daily  ingestion  of  many  pints  of 
fluid,  at  a  time  when  the  respiratory  functions  are  almost  in 
abeyance,  the  right  heart  already  embarrassed,  and  elimina- 
tion of  unused  material  difficult.  Four  or  five  ounces  of  fluid 
food  every  two  hours  is  usually  ample  for  all  requirements. 

As  a  rule  stimulants  are  not  needed  in  the  treatment  of  this 
stage  of  pneumonia,  but  in  cases  of  asthenic  or  typhoid  type, 
with  high  fever,  delirium,  tremulous  tongue,  and  rapid  com- 
pressible pulse,  they  must  be  prescribed  in  sufficient  and 
properly  regulated  doses,  the  alcohol  being  given  alternately 
with  a  mixture  containing  carbonate  of  ammonia.  The  habits 
of  the  patient  must  be  borne  in  mind  in  estimating  the  quantity 
of  stimulant  required. 

In  cases  of  low  type,  in  which  the  features  of  the  disease 
remind  one  of  idiopathic  erysipelas,  it  may  be  good  practice 
to  place  the  patient  at  once  on  twenty-  or  thirty-minim  doses 
of  tincture  of  iron,  with  half-ounce  doses  of  liquor  ammonii 
acetatis,  and  this  plan  in  alcoholic  cases  will  sometimes 
answer  without  the  aid  of  alcohol.  To  this  prescription 
five  minim  doses  of  strychnia  may  often  be  added  with 
advantage. 

2.  Stage  of  Consolidation. — The  next  period  for  treatment 
is  that  of  consolidation  of  the  lung.  At  this  stage  of  the 
disease,  from  the  fourth  or  the  fifth  day  to  the  crisis,  life  is 
most  usually  threatened  in  severe  cases  by  failure  of  the  heart 
or  hypersemia  of  the  sound  lung,  not  truly  inflammatory  {r\ 


314  DISEASES    OF   THE   LUNGS   AND   VLEITRM 

nature,  but  the  result  of  heart  failure  and  loss  of  vascular 
tone. 

It  is  sometimes  now  advisable  to  substitute  for  the  salines 
ammonia  and  bark,  in  other  cases  iron  with  acetate  of 
ammonia.  Excessive  pyrexial  symptoms  must  be  met  as 
before.  In  severe  cases  stimulants  are  necessary,  and  they 
may  often  be  usefully  combined  with  quinine.  Two-  to  five- 
grain  doses  of  quinine  should  be  given,  so  that  the  patient 
takes  from  ten  to  twenty  grains  in  the  twenty-four  hours,  and 
as  much  brandy  or  wine  as  his  symptoms  demand. 

If  signs  of  failure  of  heart  are  observed,  and  often  in  antici- 
pation of  such  arising,  small  doses  of  digitalis  (five  to  ten 
drops  of  the  tincture)  should  be  added,  either  to  the  stimulant 
or  to  the  mixture.  With  regard  to  the  usefulness  of  moderate 
doses  of  drugs  of  the  digitalis  class  in  this  period  of  pneu- 
monia, whilst  speaking  from  convincing  experience  of  the 
fact,  we  would  point  out  that  their  use  is  consistent  with  the 
most  rational  aim  in  the  treatment  of  the  disease.  Salines, 
poultices,  and  leeches  have  the  common  object  of  lessening 
pulmonary  congestion,  easing  arterial  tension,  and  depleting 
the  venous  side  of  the  circulation.  Supporting  foods  and, 
when  necessary,  alcohol,  quinine,  and  digitalis  unite  in  main- 
taining heart  power  and  tonicity  of  vessels  at  the  period  when 
these  tend  to  fail. 

In  cases  at  this  stage  in  which  the  area  of  consolidation  is 
large,  and  in  which  hypersemia  and  ensuing  cedema  of  the 
sound  lung  are  present,  the  patient  is  in  danger  from  abolition 
of  respiratory  function,  from  failure  of  heart,  and  from  ex- 
hausted nervous  system.  In  such  cases  oxygen  inhalations 
are  indicated.  These  are  given  for  two  purposes — first,  to 
sustain  heart  power;  and,  secondly,  to  maintain  respiratory 
function.  Oxygen  acts  in  the  first  case  by  increasing  the 
aeration  of  the  blood  circulating  through  the  lung,  of  which 
freshly  oxygenated  blood  the  left  ventricle  receives  the  first 
supply  through  the  coronary  vessels.  In  this  way  heart 
nutrition  is  maintained,  and  removal  of  waste  products  from 
the  cardiac  muscle  is  promoted.  For  this  primary  purpose 
ox3rgen  requires  to  be  given  early  in  the  disease,  on  the  first - 
suggestion  of  heart  failure,  and  in  doses  of  ten  minutes* 
inhalation  every  hour  or  two  hours.  Thus  administered, 
oxygen  has  the  power  of  lessening  cardio-respiratory  and 


PNEUMONIA  315 

nervous  fatigue  in  a  manner  analogous  to  that  observed  by- 
Colonel  Flack  and  others  from  its  employment  during  and 
after  aerial  flights  at  great  altitudes  or  of  long  duration,  as 
w^ell  as  after  great  and  prolonged  athletic  efforts."  Under 
this  treatment  the  pulse  will  often  be  found  to  diminish  in 
frequency,  to  increase  in  force,  and  the  patient  will  obtain 
snatches  of  refreshing  sleep.  If  the  symptoms  are  more 
urgent,  the  oxygen,  as  recommended  by  Dr.  Willcox  and 
Professor  Collingwood,^^  may  be  made  to  pass  through  a 
wash-bottle  containing  absolute  alcohol,  a  small  portion  of 
which,  being  carried  over  with  the  gas,  is  absorbed  by  the 
lung  and  conveyed  directly  to  the  heart.  The  stimulating 
effect  of  this  procedure  upon  the  pulse  is  sometimes  very 
marked.  For  the  second  purpose,  that  of  maintaining  respi- 
ratory function  over  a  crisis,  oxygen  is  administered  at  a  later 
period  of  the  disease,  and  must  then  be  given  more  or  less 
continuously.  Under  such  conditions  of  oxygen  inhalations 
an  opiate  may  in  urgent  cases  be  given  to  induce  sleep,  when 
otherwise  its  administration  would  be  attended  with  grave 
danger. 

Strychnia,  administered  hypodermically  or  otherwise,  is  of 
great  value  in  stimulating  a  failing  heart.  Caffeine  and  theo- 
bromine come  next  to  it.  These  remedies  act  partly  by  in- 
creasing arterial  tone,  and  so  retaining  a  larger  proportion 
of  blood  in  the  arterial  system,  including  the  territories  of 
the  nerve  centres,  and  partly  by  their  indirect  stimulating 
action  upon  the  cardiac  muscle  and  nerves.  In  some  cases  in 
which  the  pulse  is  peculiarly  soft  and  running,  pituitary  ex- 
tract has  in  our  experience  been  used  with  advantage. 

For  the  threatened  pulmonary  failure  above  referred  to  we 
have  found  a  combination  of  twenty-grain  doses  of  confec- 
tion of  turpentine  with  ether  and  ammonia  very  useful, 
strychnia,  either  alone  or  in  combination  with  digitalis,  being 
alternately  given  in  the  alcoholic  stimulant.  Should  signs  of 
dilatation  of  the  right  heart  supervene,  with  marked  cyanosis 
and  failing  pulse,  venesection  to  ten  or  fifteen  ounces  may  be 
practised. 

.  At  this  period  of  the  disease  the  patient  is  often  unable  to 
sleep,  or  is  the  subject  of  a  busy  delirium.  Oxygen,  as  we 
have  seen,  may  be  beneficial  in  inducing  sleep,  and  relief  is 
sometimes  given  by  an  ice-bag  resting  hghtly  on  the  head. 


3l6  DISEASES    OF   THE   LUNGS   AND   PLEURA 

or  by  a  band  of  linen  wrung  out  of  ice-cold  water  and  fastened 
round  the  forehead.  Powerful  hypnotics  must  on  no  account 
be  ordered,  but  a  mixture  containing  twenty  grains  of  chlor- 
alamide  and  twenty  grains  of  sodium  bromide  may  be 
prescribed,  or  a  drachm  of  paraldehyde,  repeated,  if  necessary, 
in  an  hour.  It  must  be  remembered  that  these  patients  can  in 
the  zenith  of  their  attack  only  obtain  sleep  in  brief  snatches, 
and  the  utmost  care  must  be  taken  by  the  attendants  to  avoid 
the  shghtest  cause  of  interruption  of  such  restorative  in- 
terludes. 

It  is  a  small  detail  to  notice,  but  one  by  which  much  comfort 
may  be  given  to  the  patient,  especially  at  this  stage,  when  the 
respiratory  passages  are  dry,  hot,  and  often  sore — viz.,  to  direct 
the  nurse  to  anoint  the  aperture  of  the  nostril  with  a  little 
olive  oil,  which,  by  trickling  into  the  passages,  keeps  them 
lubricated.  Of  much  greater  importance  is  a  careful  atten- 
tion to  the  hygiene  of  the  mouth,  which  should  be  frequently 
rinsed,  and  the  tongue  and  gums  cleansed  with  some  refresh- 
ing antiseptic  lotion.  We  have  little  doubt  that  neglect  of 
this  precaution  is  responsible  for  some  relapses  of  the  disease 
from  reinfection. 

At  the  stage  of  the  disease  now  under  consideration  the 
symptoms  and  signs  reach  their  acme,  and  the  strength  of  the 
patient  its  ebb;  the  crisis  is  anxiously  waited  for,  and  is  not 
tmattended  with  dangers  of  its  own. 

3.  Period  of  Crisis. — The  rapid  fall  of  temperature  that 
occurs  when  crisis  is  well  marked  in  pneumonia,  and  the 
copious  sweating  or  other  phenomena  attending  it,  are 
frequently  associated  with  considerable  shock  and  exhaus- 
tion. Failure  of  heart  and  pulmonary  oedema  are  the  special 
sources  of  danger.  These  must  be  met  by  carefully  support- 
ing the  patient,  temporarily  increasing  the  stimulants  to  any 
necessary  amount,  and  by  giving  moderate  (three-grain)  doses 
of  quinine  in  combination  perhaps  with  small  doses  of  digitalis. 
Sometimes  strychnia  is  more  useful  than  quinine  at  this  period. 
Port-wine  may  often  be  substituted  for  brandy. 

The  dangerous  symptoms  associated  with  crisis  pass  in  a 
few  hours,  although  sometimes  for  a  day  or  two  the  tempera- 
ture remains  subnormal.  At  the  termination  of  crisis  it  is 
often  wise  to  suspend  medicinal  treatment  altogether  for  a 
time,  regulating  the  diet  to  longer  intervals;  but  until  critical 


PNEUMONIA  '317 

discharges  have  ceased,  no  important  alteration  should  be 
made.  No  active  measures  should  be  taken  to  arrest  such 
discharg'es. 

4,  Resolution  Stage. — During  the  early  part  at  least  of  this 
fourth  period  of  pneumonia  (as  we  have  artificially  divided 
the  phases  of  that  disease)  the  same  recuperative  measures 
should  be  continued,  strict  rest  in  bed  being  still  enjoined,  the 
dietary  being  gradually  improved,  some  soHds  allowed,  and 
the  stimulants  (if  any  used)  cautiously  curtailed,  and  changed 
to  port-wine  or  malt-liquors.  The  condition  of  the  tongue 
will  be  the  guide  on  these  points. 

The  secretions  from  the  kidney  and  bowel  must  be  looked 
to,  for  it  must  be  remembered  that  inflammatory  products  are 
being  absorbed  and  eliminated.  After  a  few  days,  simple 
quinine  or  quinine  and  iron  tonics,  or  a  little  mineral  acid 
twice  daily,  may  be  usefully  employed.  The  resolution  as  a 
rule  proceeds  steadily  and  satisfactorily.  In  some  cases,  how- 
ever, as  already  pointed  out,  a  secondary  and  recurrent  rise 
of  temperature,  with  slight  chills  and  sweatings,  attends  the 
process.  Quinine  must  then  be  steadily  continued,  or,  if  this 
drug  disagree,  arsenic  may  be  tried,  the  patient  being  kept 
strictly  at  rest. 

After  a  consolidation  has  cleared  up,  it  is  not  uncommon  for 
there  to  be  some  return  of  crepitation  over  the  seat  of  past 
pneumonia;  this,  which  is  doubtless  due  to  local  atonicity  of 
vessels  favouring  a  passive  congestion,  is  best  treated  by  the 
employment  of  tincture  of  iron  internally.  An  analogous  con- 
dition is  not  infrequently  met  with  in  acute  nephritis,  in  the 
course  of  convalescence,  which  may  lead  to  temporarily  in- 
creased albuminuria  without  any  associated  rise  of  tempera- 
ture. 

Counter-irritants  are  occasionally  useful  in  resolving  pneu- 
monia, and  two  or  three  grains  of  iodide  of  potassium,  in  com- 
bination with  citrate  of  iron  and  quinine,  will  sometimes 
hasten  convalescence  in  indolent  cases. 

Change  of  air  is  needed  to  complete  convalescence,  and  in 
no  disease  is  it  more  important  that  perfect  recovery  should 
be  effected.  The  only  conditions  that  need  be  specially  ob- 
..  served  wnth  regard  to  such  change  are  the  avoidance  of  damp, 
low-lying,  ill-drained  localities,  and  the  choice  of  places  where 
the    patient    can    obtain    exercise    on    level    ground.     Some 


3l8  DISEASES    OF  THE  LUNGS   AND   PLEURA 

patients  will  recover  best  at  the  seaside;  others,  of  a  more 
nervous  temperament,  often  do  better  inland. 

Sphacelus  of  the  Lung. — In  rare  instances  it  happens  that 
the  expectoration  in  pneumonia  becomes  foetid  or  distinctly 
gangrenous.  In  sHght  cases  such  antiseptics  as  formalin 
solution  or  eucalyptus  may  be  inhaled,  but  there  is  no  more 
potent  disinfectant  than  strongly  pushed  oxygen  inhalations. 
When  the  sloughing  of  the  lung  is  extensive,  and  a  gan- 
grenous cavity  is  formed,  it  will  be  necessary  to  call  in  surgical 
assistance  (see  p.  365). 

In  puruleni  infiltration  of  the  lung  we  cannot  do  more  than 
try  to  support  the  patient  by  bark  and  ammonia,  wine  and  food. 

In  circumscribed  abscess  we  must  endeavour  to  keep  the 
abscess  cavity  as  empty  and  disinfected  as  possible,  by  change 
of  posture,  and  the  use  of  disinfectant  inhalations  as  for 
sphacelus,  and  at  the  same  time  to  maintain  the  patient's 
strength.  Surgical  interference  may  again  in  these  cases  be 
necessary,  but  it  should  not  be  too  hastily  adopted,  the 
abscess  frequently  contracting  under  ordinary  treatment  (see 
Chapter  XXII. 

In  the  treatment  of  septic  pneumonia,  quinine,  sometimes 
iron,  and  a  liberal  allowance  of  stimulants,  are  our  most 
reliable  remedies. 

Specific  Treatment. — With  the  discovery  of  the  diphtheritic 
serum  and  the  recognition  of  its  valuable  curative  properties 
it  seemed  reasonable  to  hope  that  a  similar  serum  mig^ht  prove 
of  equal  value  in  cases  of  pneumonia.  Various  antipneu- 
mococcic  sera  have  accordingly  been  prepared,  but  though  an 
encouraging  case  has  been  met  with  from  time  to  time,  the 
results  obtained  by  their  employment  have  on  the  whole  been 
disappointing. 

The  recent  work  of  the  Rockefeller  Institute,  to  which  we 
have  alluded,  and  the  success  obtained  by  Dr.  Men^yn  Gordon 
in  the  treatment  of  cerebro-spinal  fever  have,  however,  opened 
a  new  and  more  hopeful  vista.  Dr.  Gordon-'  showed  that  the 
meningococcus,  like  the  pneumococcus,  could  be  differentiated 
by  the  agglutination  test  into  four  main  groups  or  types,  and 
that  if  in  a  given  patient  the  type  of  meningococcus  present 
was  determined  and  the  patient  treated  with  the  serum  appro- 
priate to  this  type,  so-called  "monotypical  serum,"  then  the 
results  were  highly  satisfactory,  the  mortality  being  reduced 


PNEUMONIA  319 

from  60-70  to  12  per  cent.  As  in  the  case,  however,  of  the 
monotypical  antipneumococcic  serum  to  be  mentioned  later, 
the  results  have  been  better  in  Type  I.  cases  than  in  those 
infected  by  other  varieties  of  the  meningococcus.  Apparently 
the  presence  in  the  serum  of  sufificient  anti-endotoxic  capacity 
is  an  essential  factor. 

Work  on  similar  hues  has  been  carried  out  at  the  Rockefeller 
Institute  in  the  case  of  the  pneumococcus  with  promising 
though  less  striking  results.  As  we  have  seen  (see  p.  291),  at 
least  four  types  of  pneumococcus  have  been  differentiated  in 
New  York,  and  sera  corresponding  to  Types  I.,  II.,  and  III. 
have  been  prepared.  Of  these,  the  sera  produced  by  the 
injection  into  horses  of  Types  II.  and  III.  appear  to  be  in- 
effective, but  in  regard  to  the  serum  of  Type  I.  it  is  different. 
If  patients  suffering  from  pneumonia  due  to  a  pneumococcus 
of  this  strain  are  treated  with  the  corresponding  serum  the 
mortality  is  much  diminished.  Of  107  cases  thus  treated 
eight  only  died,  a  mortality  of  7-5  per  cent,  as  contrasted  with 
a  death-rate  of  25  per  cent,  before  the  serum  treatment  was 
introduced."-^ 

To  be  effective,  the  serum  must  be  given  intravenously  and 
in  large  doses,  so  that  a  sufificient  concentration  of  antibodies 
may  be  effected.  An  injection  of  90  to  100  c.c.  of  serum,  slowly 
administered,  is  recommended  as  soon  as  possible,  this  dose  to 
be  repeated  every  eight  hours  until  a  favourable  result  has 
been  effected.  On  an  average  250  c.c.  of  the  serum  are  thus 
given.'"*'  With  these  large  doses  symptoms  of  anaphylaxis'"'^' 
may  manifest  themselves,  if  the  patient  be  highly  sensitive  to 
horse  serum,  and  in  every  case  before  injecting  the  serum  the 
sensibility  of  the  patient  should  be  tested  by  means  of  the 
intradermal  skin  test,  and  even  if  negative,  a  subcutaneous 
injection  of  ■;^  to  i  c.c.  of  the  serum  should  be  given,  which  is 
effective  in  producing  desensitisation  in  patients  who  are  but 
slightly  hypersensitive.  If  the  skin-test  be  positive,  showing 
the  patient  to  be  highly  sensitive,  then  the  serum  must  be  given 
every  half  hour,  at  first  subcutaneously  and  then  intravenously, 
in  extremely  small  doses,  commencing  with  0-025  c.c,  doubling 
the  dose  at  each  injection.  Such  a  thorough  desensitisation  is 
a  lengthy  process,  but  it  has  only  been  found  necessary  in 
about  2  per  cent,  of  the  cases. 

Mild  symptoms  of  serum  sickness  also  manifest  themselves 


320  DISEASES   OF   THE  LUNGS   AND   PLEURA 

in  nearly  half  the  patients  treated  with  the  serum,  some  one  to 
two  weeks  after  the  injections,  and  in  about  lo  per  cent,  the 
attacks  are  severe. 

It  is  possible  that  as  more  potent  sera  are  produced, 
obviating  the  necessity  for  such  large  doses,  these  troublesome 
complications  may  become  less  frequent.  It  is  obvious  also 
that  at  the  present  phase  of  experience  observations  such  as 
these  could  he  carried  out  only  under  strict  control  and  in 
hospital  practice.  We  have  said  enough,  however,  to  show 
that,  based  as  it  now  is  on  scientific  principles,  the  outlook  in 
regard  to  the  serum  treatment  of  pneumonia  is  more  favour- 
able than  it  was  a  few  years  ago,  and  that  further  develop- 
ments may  confidently  be  expected. 

Following  the  lines  advocated  by  Sir  Almroth  Wright, 
pneumocGccic  vaccines  have  also  been  employed.  The  usual 
procedure  has  been  to  give  in  the  adult  an  initial  subcutaneous 
injection  of  from  20  to  30  millions  of  stock  pneumococcic 
vaccine,  and  to  follow  this  up  by  the  use  of  an  autogenous 
vaccine  from  the  patient's  sputum  as  soon  as  this  can  be  pre- 
pared. We  have  employed  such  vaccines  in  many  cases  of 
pneumonia,  but  are  not  satisfied  that  we  have  seen  any  marked 
improvement  follow  their  use.  If  cautiously  given  they  appear 
to  be  without  harmful  effect.  We  have  also  tried  sensitised 
vaccines — that  is  to  say,  vaccines  (by  preference  autogenous) 
previously  treated  by  being  placed  for  some  time  in  contact 
with  antipneumococci  serum,  after  the  method  of  Besredka, 
and  perhaps  with  more  encouraging  results. 


25 


REFERENCES. 

^  "  Memorandum  on  the  Incidence  of  Fatal  Pneumonia,"  by  G.  B. 
Longstaff,  M.A.,  M.B.  (Oxon),  F.S.S.  See  The  Collective  Investigation 
Record,  edited  for  the  Collective  Investigation  Committee  of  the  British 
Medical  Association  by  Professor  Humphry,  M.D.,  F.R.S.,  and  F.  A. 
Mahomed,  M.B.,  F.R.C.P.,  vol.  ii.,  p.   102.     London,   1884. 

^  {a)    See    "  Pneumonie   Lobaire,"    par    M.    le   Dr.    Netter,    Traite    de 
Medecine  publiee  sous  la  direction  de  MM.  Bouchard  et  Brissaud, 
deuxieme  edition,  tome  vi.,  p.  487,  1901. 
[b)  Lac.  cit.,  p.  486. 

^  "  Remarks  on  Pneumonia,"  by  Assistant-Surgeon  Welch,  Army  Medical 
Department;  Report  for  the  year  1867,  vol.  ix.,  Appendix  IX.,  p.  329. 
London,  1869. 

*  Traumatic  Pneumonia  and  Traumatic  Tuberculosis,  by  F.  Paxkes 
Weber,  M.A.~   M.D.,  F.R.C.P.     London,  1916. 


PNEUMONIA  321 

*   See  "  Epidemics  of  Pneumonia,   British  and  Foreign  "   ^with  Biblio- 
graphy),  by   Dr.    Octavius    Sturges   and   Dr.    Sidney   Coupland,    in   The 
Collective  Investigation  Record,  vol.  ii.,  pp.   5-26.     London,   1884. 
^  {a)  "  Analysis  of  the  Returns.     Note  on  the  Etiology  of  Pneumonia," 
Collective  Investigation  Record,  vol.  ii.,  p.  60.     London,  1884. 
See  also  (b)  "  Epidemic  Pneumonia,"  British  Medical  Journal,  1912, 
vol.  i.,  p.  1432. 
^  (i)  "An  Epidemic  of  Pneumonia  in  the  Punjab,"  by  Surgeon-Major 
S.    E.    Maunsell,    Collective   Investigation    Record,    vol.    ii.,    p.    77. 
London,  1884. 
(2)  "  Remarks  on  a  Second  Epidemic  of  Pneumonia  occurring  in  the 
Punjab,    Bengal,     1882-83,"    by    Surgeon-Major    S.     E.     Maunsell. 
Collective  Investigation  Record,  vol.  ii.,  p.  93.     London,   1884. 
'  The    Natural    History    and    Relations     of    Pneumonia:    Its    Causes, 
Forms,  and  Treatment,  by  Octavius  Sturges,  M.D.,  and  Sidney  Coupland, 
M.D.,  second  edition,  p.  329.     London,  1890. 
'   (i)   Diseases  of  the   Organs   of   Respiration,  by   Samuel  West,    M.D., 
second  edition,  vol.  i.,  p.  253.     London,  1909. 
(2)  "  Some  of  the  Less  Common  Aspects  of  Pneumonia,"  by  Sir  Thomas 
Oliver,  M.D.,  British  Medical  Journal,  1910,  vol.  i.,  p.  1033. 
"   (a)   "  Acute  Lobar   Pneumonia  :   Prevention  and  Serum   Treatment " 
(with  Bibliography),  by  Oswald  T.  Avery,  M.D.,  H.  T.  Chickering, 
M.D.,  Rufus  Cole,  M.D.,  and  A.  R.  Dochez,  M.D.,  Monographs  of 
the  Rockefeller  Institute  for  Medical  Research,   No.    7,   October    16, 
1917,  p.  93.     New  York,  1917. 
(d)  Loc.  cit.,  p.  7. 
(<r)  Loc.  cit.,  p.  2>Z- 
((f)  Loc.  cit.,  p.  90. 
(£)  Loc.  cit.,  p.  35. 
(/)  Loc.   cit.,  p.  79. 
{g)  Loc.  cit.,  p.  68. 
(h)  Loc.  cit.,  pp.  62-64.         • 
"  "  Sur   rfitiologie   de   la   Pneumonic   fibrineuse  chez   I'Homme,"    par 
M.  N.  Gamaleia,  Annales  de  VInstitut  Pasteur,  1888,  vol.  ii.,  p.  451. 

*2  "An  Experimental  Study  of  Prophylactic  Inoculation  against  Pneu- 
mococcal Infection  in  the  Rabbit  and  in  Man,"  by  F.  S.  Lister,  M.R.C.S., 
L.R.C.P.,  The  South  African  Institute  for  Medical  Research  (No.  viii.), 
p.  6.     Johannesburg,  1916. 

"  "  Note  sur  la  Maladie  nouvelle  provoquee  par  la  salive  d'un  enfant 
mort  de  la  rage,"  par  M.  Pasteur,  Bulletin  de  VAcadimie  de  Medecine, 
Paris,  1881,  2'"<>  serie,  tome  x.,  p.  94. 

"  See  (i)  "  Observations  on  Metabolism  in  the  Febrile  State  in  Man," 
by  G.  C.  Garratt,  M.D.,  Transactions  of  the  Royal  Medical  and 
Chirurgical  Society,  1904,  vol.  Ixxxvii.,  p.  163. 
(2)  "  Chloride  Metabolism  in  Pneumonia  and  Acute  Fevers,"  by 
Robert   Hutchison,    M.D.,    Journal  of   Pathology   and   Bacteri- 
ology, 1898,  vol.  v.,  p.  406. 
"  See  "  A  Clinical  Lecture  on  a  Case  of  Acute  Sthenic  Pneumonia  left 
without   Treatment,"   by   E.    A.    Parkes,    M.D.,    The   Medical  Times   and 
Gazette.     London,  i860,  p.    184, 

21 


322  DISEASES    OF   THE   LUNGS   AND   PLEURA 

^8  "  Contribuzione  sulle  polmoniti  massicce,"  pel  Dottor  Luigi  M. 
Petrone,  Lo  Sferimentale,  Firenze,  1882,  vol.  1.,  p.  449. 

"  "  Contributions  to  the  Etiology  of  Continued  Fever,"  by  Charles  Mur- 
chison,  M.D.,  Transactions  of  the  Royal  Medical  and  Chirurgical  Society, 

1858,    vol.    Xli.,    p.    221. 

18  "  Pythogenic  Pneumonia,"  by  Thomas  Wrigley  Grimshaw,  A.M., 
M.D.,  and  John  William  Moore,  M.D.,  The  Dublin  Journal  oj  Medical 
Science,  1875,  vol.  lix.,  p.  399. 

"  "On  Creeping  Pneumonia  (Pneumonia  Migrans)  and  its  Relation  to 
Epidemic  Pneumonia,"  by  J.  Dreschfeld,  M.D.,  F.R.C.P.,  The  Medical 
Chronicle.     Manchester,   1885,  vol.  ii.,  p.  353. 

^o  "  A  Discussion  on  Pneumonia  and  its  Complications,"  Proceedings  of 
the  Royal  Society  of  Medicine  (Medical  Section),  November  and  December, 
1907,  vol.  i.,  Nos.  1  and  2. 

^1  "  IJber  die  prognostische  Bedeutung  des  Herpes  bei  der  Pneumonie," 
von  Dr.  H.  Th.  Geissler  (zu  Leipzig),  Archiv  der  Heilkunde.  Leipzig, 
1861,  Band  ii.,  p.  115. 

2"  "Reports  on  the  Physiological  and  Medical  Aspects  of  Flying  made 
to  the  Medical  Research  Committee,"  by  Lieut. -Colonel  Martin  Flack, 
R.A.F.,  Nos.  I  and  4,  February  and  November,   1918. 

2'  "  The  Therapeutic  Use  of  Alcohol  Vapour  mixed  with  Oxygen,"  by 
W.  H.  Wilcox,  M.D.,  F.R.C.P.,  and  Professor  B.  J.  Collingwood,  M.D., 
British  Medical  Journal,  1910,  vol.  ii.,  p.   1408. 

'^  The  S  feci  fie  Treatment  of  Cerebrospinal  Fever,  with  an  Analysis 
of  the  Reforts  on  the  First  Ninety  Cases  treated  with  Monotyfical  Sera, 
by  T.  G.  M.  Hine,  M.D.,  with  Introductory  Note  by  M.  H.  Gordon, 
C.M.G.,  M.D.,  Medical  Research  Committee,  London,  January  28,  1919. 

^^  See  "  Results  Obtained  with  Sensitised  Vaccine  in  a  Series  of  Cases 
of  Acute  Bacterial  Infection,"  by  H.  M.  Gordon,  M.D.,  Proceedings  of  the 
Royal  Society  of  Medicine,  1913.,  vol.  vi.  (Therapeutical  and  Phar- 
macological Section),  pp.   153-176. 


CHAPTER  XVIII 

BRONCHO-PNEUMONIA 

Broncho-pneumonia,  or  lobular  inflammation  of  the  lung, 
affects  certain  lobules  of  the  organ  and  their  associated  bron- 
chioles. The  inflammatory  lesion  is  not,  however,  always 
strictly  confined  to  separate  lobules  or  groups  of  lobules,  for 
in  some  cases  more  diffused  areas  of  lung  become  affected, 
until,  perhaps,  a  whole  lobe  may  be  involved. 

.ffitiology. — Broncho-pneumonia  may  occur  as  a  primary 
disease,  apart  from  any  pre-existing  bronchitis  or  other  antece- 
dent condition,  and  as  such  is  most  frequently  met  with  in 
infancy  and  early  childhood.  This  variety,  to  which  the  late 
Dr.  Samuel  West^  drew  attention,  is  less  common  than  the 
secondary  form,  and  in  its  clinical  features  resembles  closely 
the  lobar  pneumonia  of  the  adult,  and  like  the  latter  would 
appear  to  be  produced  by  the  pneumococcus. 

Secondary  hroncho-pneufnonia,  whether  consequent  upon 
simple  bronchitis,  measles,  whooping-cough  or  diphtheria,  is 
also  most  commonly  observed  in  infancy  and  early  childhood, 
and  occurs  especially  among  the  badly-nourished  children  of 
the  poor.  As  a  disease  secondary  to  influenza,  phthisis, 
tracheotomy,  pyaemia  and  allied  conditions,  it  may  occur  at 
any  age. 

In  the  great  majority  of  cases  the  malady  is  produced  by  the 
inhalation  of  septic  material  of  varied  nature  into  the  finest 
bronchi  and  alveoli.  In  those  cases  in  which  bronchitis  is 
already  present,  the  inflammation  of  the  alveoli  may  be  attrib- 
uted to  extension,  or  to  the  aspiration  of  infected  secretions 
from  the  bronchi  backwards,  or  their  projection  into  the 
alveoli  during  deep  respiratory  or  tussive  efforts. 

In  phthisis  the  aspiration  of  blood  or  sputum  in  the  course 
of  expectoration  frequently  sets  up  in  a  similar  manner  new 
centres  of  lobular  inflammation  and  infection.     After  trache- 

323 


324  DISEASES   OF  THE  LUNGS   AND   PLEURA 

otomy  also,  when  the  mechanism  of  cough  and  expectoration 
is  impaired  through  defect  in  the  glottis,  altered  blood,  puru- 
lent secretions  and  septic  matters  are  easily  inhaled  into  the 
lungs,  and  give  rise  to  lobular  pneumonia. 

Closely  connected  with  the  preceding  is  the  so-called 
"  deglutition  pneumonia."  In  this  variety,  either  during  coma 
or  from  paralysis  of  the  larynx,  food  and  secretions  from  the 
mouth,  or  even  the  stomach,  pass  the  glottis,  and,  failing  to 
excite  the  usual  expiratory  efforts,  reach  the  finest  bronchi,  and 
thus  produce  broncho-pneumonia.  The  pneumonia  which 
sometimes  follows  surgical  operations  has  no  doubt,  in  part  at 
least,  a  similar  explanation,  since  it  has  been  shown  that  during 
anassthesia  mucus  and  saliva  may  be  inhaled  into  the  air- 
passages,  but  the  nature  of  the  anaesthetic,  the  skill  with 
which  it  is  administered,  and  the  disturbance  of  respiratory 
movements,  also  play  a  part.^ 

Broncho-pneumonia  of  a  septic  type  may  follow  the  inhala- 
tion of  the  virulent  gases  now  used  in  warfare.  This  is 
especially  apt  to  occur  in  the  case  of  mustard  gas — dichlor- 
ethyl-sulphide,  (C2H4C1)2S,  the  vapour  leading  first  to  a  destruc- 
tion and  sloughing  of  the  mucous  membrane  of  the  trachea, 
bronchi  and  bronchioles,  and  then  to  a  secondary  invasion  of 
organisms  from  the  sloughing  surfaces,  producing  broncho- 
pneumonia and  sometimes  death.  Analogous  to  this  are  the 
cases  in  civil  life  in  which  catarrhal  pneumonia  has  followed 
exposure  to  acrid  vapours,  such  as  the  pungent  smoke  from  a 
burning  building. 

Septic  organisms  may  reach  the  alveoli  through  the  blood, 
as  in  pysemia,  septicaemia,  and  in  certain  forms  of  tuberculosis. 
In  such  cases  the  lesions  affect  vascular  rather  than  bronchial 
areas. 

Bacteriology. — With  the  possible  exception  of  the  rare  cases 
which  follow  the  inhalation  of  pungent  vapours,  broncho- 
pneumonia, however  arising,  is  always  produced  by  the  action 
of  micro-organisms.  No  one  organism,  however,  is  always  at 
fault,  but  under  different  circumstances  now  one  and  now 
another  may  produce  it. 

From  the  observations  of  Dr.  Wollstein^  it  would  appear 
that  primary  broncho-pneumonia,  like  lobar  pneumonia  in  the 
adult,  is  to  be  attributed  to  the  action  of  the  pneumococcus. 
Broncho-pneumonia  secondary  to  bronchitis  is  traceable  to  a 


BRONCHO-PNEUMONIA  325 

variety  of  organisms  often  acting  in  conjunction,  among  which 
the  pneumococcns  and  the  streptococcus  pyogenes  figure  most 
prominently,  and  less  frequently  the  staphylococcus  pyogenes 
aureus  and  albus,  the  micrococcus  catarrhalis,  the  influenza 
bacillus,  and  other  organisms,  as  shown  by  Dr.  Eyre's* 
extended  observations.  With  regard  to  the  broncho-pneu- 
monias which  occur  in  the  course  of  specific  fevers,  we  have 
pointed  out  elsewhere^  that  the  inflammation  may  be  produced 
by  the  specific  micro-organism  of  the  disease  (homologous 
infection)  or  by  a  mixed  specific  and  pyococcal  infection 
(mixed  infection);  in  rarer  cases  it  results  from  the  action  of 
the  pyogenic  cocci  or  other  organisms  only  (heterologous 
infection). 

The  following  bacterial  classification  of  broncho-pneumonia, 
based  upon  that  which  we  ventured  to  offer  some  years  ago,  at 
the  suggestion  of  the  late  Professor  Kanthack,  illustrates  these 
points  :^ 

The  Bacteriology  of  Acute  Broncho-Pneumonia. 

I. — Primary — ^produced  by  the  pneumococcus. 

II. — Secondary  : 

Pneumococcus 
Streptococcus  pyogenes 
Staphylococcus  aureus  and  albus 
Bacillus  influenzse 
Micrococcus  catarrhalis 
Micrococcus  tetragenus 
Bacillus  of  Friedlander,  etc. 

2.  Occurring  in  the  Course  of  Various  Specific  Infections,  such  as  Diphtheria, 
Influenza,  Pertussis,  Measles,  Scarlet  Fever,  Typhoid  Fever, 
Tuberculosis,  and  Plague. 

(a)  Homologous — produced    by    the    specific    organism    of    the 

disease. 
(&)  Mixed  infection — specific  and  pyococcal. 
(c)  Heterologous — produced  by  secondary  pyococcal  infection. 

Morbid  Anatomy. — The  bronchi  are  always  more  or  less  in- 
flamed, and  in  the  secondary  form,  with  which  we  are  chiefly 
concerned,  are  filled  with  thick  muco-purulent  secretion.  As 
the  inflammation  extends,  portions  of  collapse  are  found  in 
various  parts  of  the  lung,  in  others  patches  of  inflammation; 
but  the  collapsed  portions  themselves  are  often  attacked  with 
pneumonia. 

The  pneumonic  patch  feels  like  a  hard  nodule  in  the 
substance  of  the  lung.  If  of  small  size,  it  will  be  seen  on 
section  to  be  more  or  less  conical  in  shape,  with  the  base 


I.  To  Bronchitis — - 


The  infection  is 

often  a  mixed 

one. 


326 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


towards  the  periphery  of  the  lung  and  projecting  above  the 
surrounding  surface,  thus  distinguishing  it  from  a  patch  of 
collapse.  If  of  larger  size,  the  pleura  over  it  is  often  involved. 
The  portion  of  lung  affected  is  dark  red  in  the  earliest  stages, 
and  then  gradually  assumes  a  greyish  colour.  The  cut  surface 
is  soft,  breaks  more  easily  than  the  normal  lung,  and  is  finely 
granular.  On  squeezing  it  a  reddish  juice  exudes,  with 
perhaps  a  drop  of  purulent  secretion  from  the  central 
bronchus.  Adjoining  patches  tend  to  coalesce,  and  thus  the 
greater  portion,  and  indeed  the  whole,  of  one  lobe  may  become 
affected,  forming  the  confluent  or  "pseudo-lobar  "  variety  of 
the  disease.    In  cases  of  septic  origin,  such  as  may  occur  after 


Fig.  32. — Section  of  Lung  :  Broncho-Pneumonia. 

operations  on  the  mouth  and  tongue,  small  abscesses,  from 
central  softening  of  the  patches,  are  often  found,  surrounded 
by  consolidated  lung. 

The  microscopical  appearances  in  a  case  of  broncho-pneu- 
monia differ  somewhat,  according  to  the  acuteness  of  the 
process  and  the  nature  of  the  irritant.  In  an  acute  case,  in  its 
earliest  stage,  the  appearances  will  closely  resemble  those  of 
acute  lobar  pneumonia;  indeed,  as  the  late  Professor  Kanthack 
first  insisted,  it  is  anatomically  incorrect  to  draw  any  hard-and- 
fast  distinction  between  them.  Thus  many  of  the  alveoli  will 
be  found  to  contain  red  and  white  blood-corpuscles,  and  not 
uncommonly  a  fibrin  network,  whilst  the  epithelium  lining  the 
alveoli  is  swollen  and  granular.  At  a  later  stage,  or  in  less 
acute    cases,    with    which,    perhaps,    we    are    more    familiar 


BRONCHO-PNEUMONIA  327 

(Fig.  32),  numerous  desquamated  and  swollen  epithelial  cells, 
mingled  with  leucocytes,  are  found  occupying  the  alveoli,  but 
fibrin  and  red  corpuscles  are  not  visible.  Later,  as  resolution 
proceeds,  the  cells  undergo  fatty  degeneration,  and  the 
products  are  removed,  partly  by  absorption  and  partly  by 
expectoration. 

Symptomatology.  —  Cases  of  primary  broncho-pneumonia 
occurring"  in  young  children  run  a  course  very  similar  to  that 
of  lobar  pneumonia.  The  disease  sets  in  suddenly,  perhaps 
with  a  convulsion ;  the  temperature  remains  high,  and  falls  by 
crisis  on  about  the  seventh  day,  after  which  the  child  rapidly 
recovers.  The  signs  of  bronchitis  are  less  marked  than  in  the 
secondary  variety,  and  physical  examination  reveals  small 
scattered  areas  of  consolidation.  The  disease  would  appear,  in 
.  fact,  to  be  a  pneumococcic  inflammation  of  the  lung  analogous 
to  the  lobar  disease  in  the  adult,  but  which  in  the  child  takes 
on  a  lobular  form. 

In  describing  the  clinical  features  of  secondary  broncho- 
pneumonia, under  which  are  included  the  majority  of  cases 
seen,  we  shall  have  in  our  mind  especially  cases  of  infantile 
type,  such  as  those  arising  in  association  with  bronchitis  or 
whooping-cough.  Clinically,  two  forms  of  this  disease  are 
met  with,  the  disseminated  and  the  confluent. 

I.  The  Disseminated  Form. — In  this  variety  the  symptoms 
are  those  of  capillary  bronchitis,  which  invariably  coexists. 
In  young  children  the  distinction  between  the  two  diseases  is 
often  impossible,  and  is  practically  of  but  little  importance. 
When  the  disease  supervenes,  however,  upon  a  less  urgent 
bronchitis,  its  access  is  marked  by  a  rise  of  temperature,  an 
increased  dyspnixa,  and  a  greater  rapidity  of  pulse.  Shivering 
is  rarely  to  be  noted  in  young  children,  and  its  analogue, 
convulsion,  is,  so  far  as  our  experience  goes,  uncommon  in 
this  form  of  pneumonia. 

The  rise  of  temperature  is  generally  above  102°,  but 
although  the  range  or  average  of  temperature  is  above  that 
of  bronchitis,  it  is  less  maintained  and  more  fluctuating  in 
character  than  in  croupous  pneumonia.  The  dyspnoea,  at  first 
urgent,  with  flushed  face  and  working  alae  nasi,  and  with  a 
characteristic  "  expiratory  giimt,"  becomes  less  apparent  as 
the  strength  of  the  little  patient  fails  and  his  nervous  centres 
become  less  sensitive  in  the  struggle.    Pallor  of  countenance 


328  DISEASES    OF   THE   LUNGS   AND   PLEURA 

with  perhaps  a  faint  tinge  of  Hvidity  appears,  and  the  skin 
becomes  moist  and  even  perspiring.  The  rapidity  of  breathing 
continues,  however,  or  increases,  and  on  uncovering  the  chest 
and  abdomen,  recession  of  soft  parts  with  inspiration  is 
observed.  The  pnlse  becomes  more  frequent  and  of  lessened 
force.  The  tongue  is  from  the  first  thickly  coated,  the  lips  dry, 
the  urine  scanty  and  depositing  lithates,  and  the  bowels  dis- 
ordered, constipated,  or,  it  may  be,  relaxed. 

The  physical  signs  of  this  disseminated  form  of  the  disease 
are  not  very  characteristic.  The  percussion  note  is  either  un- 
altered or  is  somewhat  raised  and  of  semi-tympanitic  quality. 
Auscultation  reveals  fine  sub-crepitant  or  small  bubbling  rales 
scattered  over  both  lungs,  most  abundant  at  the  posterior 
bases.  Over  other  parts  of  the  lungs  a  patchy  distribution  of 
the  rales  may  sometimes  be  recognised,  and  is  then  of  value  in 
diagnosis.  The  rales  are  persistent,  not  being  appreciably 
cleared  by  cough,  and  are  often  better  heard  immediately  after 
cough.  '  The  breath-sounds  are  notably  enfeebled  and  masked. 
Patches  of  tubular  breathing  may  sometimes  be  discovered. 

Should  recovery  take  place,  the  pyrexia,  which  often  lasts 
two  to  three  weeks  or  longer,  gradually  subsides  with  con- 
siderable fluctuations,  the  physical  signs  clear  up,  the  tongue 
cleans,  appetite  returns,  but  strength  is  only  slowly  recovered. 
This  form  of  broncho-pneumonia  is,  however,  of  a  grave 
character,  often  proving  fatal,  and  in  all  cases  leaving  behind 
pulmonary  delicacy.  Indeed,  the  disease  may  be  said  rarely 
to  occur  in  children  who  are  of  good  stock  and  in  good 
previous  health. 

2.  The  Confluent  Form. — This  form  of  the  disease,  some- 
times also  spoken  of  as  "  pseudo-lobar,"  does  not  essentially 
differ  in  its  pathology  from  the  preceding,  but  the  adjacent 
lobules  of  a  large  portion  of  lung,  sometimes  involving  the 
whole  lobe,  are  affected,  thus  producing  more  or  less  dense 
consolidation.  This  variety  may  be  associated  with  ordinary 
bronchitis  of  catarrhal  origin,  and  often  occurs  in  the  course 
of  whooping-cough.  We  have  also  met  with  it  in  certain  cases 
of  heart  disease,  and  as  a  compHcation  in  pulmonary  tuber- 
culosis. 

The  symptoms  of  the  disease  are  identical  with  those  of  the 
preceding  variety,  except  t-hat  pleuritic  pain  is  more  commonly 
experienced  on  the  side  attacked.      The  physical  signs  are 


BRONCHO-PNEUMONIA  329 

somewhat  different.  The  pulse  and  respirations  are  similarly 
quickened,  and  the  signs  of  obstructed  inspiration  are 
observed,  but  not  symmetrically,  the  expansion  on  the  affected 
side  being,  in  cases  in  which  the  disease  is  at  all  extensive, 
notably  diminished.  Most  commonly  the  posterior  and  lower 
portion  of  one  lung  is  affected,  and  over  this  region  the  per- 
cussion note  is  distinctly  impaired,  in  the  earlier  stages 
having  a  somewhat  skodaic  quality,  but  as  the  lobules  coalesce 
becoming  more  toneless.  Vocal  fremitus  in  young  children  is 
of  no  value,  and  children  who  are  seriously  ill  with  broncho- 
pneumonia rarely  cry;  but  if  produced  under  auscultation,  the 
cry  is  bronchophonic  in  character,  with  a  tendency  towards 
segophony.  The  breath-sound  over  the  consolidated  area  is 
weak  and  bronchial,  being  considerably  masked  by  abundant 
sub-crepitant  rales  of  sharply-defined  or  metallic  character. 
The  disease  may  affect  both  sides,  but  as  a  rule  the  opposite 
lung  is  affected  with  bronchitis  only,  or  it  may  be  with  a  few 
centres  of  disseminated  pneumonia.  The  temperature  and 
other  phenomena  in  this  form  of  the  disease  are  the  same  as  in 
the  preceding. 

There  is  a  greater  tendency  for  this  variety  of  broncho- 
pneumonia to  become  chronic,  and  to  run  a  long  course  of 
perhaps  many  months,  terminating  in  pulmonary  fibrosis  with 
bronchiectasis  or  in  pulmonary  tuberculosis.  The  mere  extent 
of  the  disease  in  the  early  stage  may,  however,  prove  fatal;  in 
other  instances  it  proceeds  to  suppurative  destruction  of  lung 
and  to  the  death  of  the  patient.  The  signs  of  suppuration  are 
increased  prostration,  adynamia,  maintained  rapidity  of  pulse, 
fluctuating  temperature,  and  hectic  sweatings,  with  rapid  loss 
of  flesh.  The  rales  become  larger,  more  bubbling,  even 
gurgling,  in  character;  and  although  children  rarely  expec- 
torate, it  is  obvious  that  much  secretion  comes  up  to  the  throat, 
and  irritative  diarrhoea  with  slimy  stools  frequently  supervenes 
as  the  result  of  it  being  swallowed. 

Treatment. — The  treatment  of  broncho-pneumonia  is  mainly 
that  of  bronchitis.  In  the  disseminated  form  of  the  disease  it 
is  doubtful  if  poultices  are  of  any  service,  and  it  is  most  im- 
portant that  the  respiratory  movements  be  allowed  as  free  play 
as  possible.  In  the  more  localised  confluent  form  poulticing  is 
sometimes  useful.  The  timely  use  of  emetics  in  whooping- 
cough  will  sometimes  avert  the  occurrence  of  broncho-pneu- 


336  DISEASES    OF  THE  LUNGS   AND   PLEURA 

monia,  but  it  must  be  allowed  that  the  disease  is  often  started 
by  the  imprudent  exposure  of  children  with  whooping-cough 
to  cold  winds  under  the  delusion  that  in  this  disease  such 
exposure  is  harmless  or  beneficial.  A  careful  nurse  or  mother 
who  understands  how  to  hold  a  child  during  the  paroxysms  of 
whooping-cough,  so  as  to  permit  the  fullest  play  to  the 
respiratory  muscles,  may  help  much  in  averting  pulmonary 
collapse  and  subsequent  pneumonia. 

The  room  should  be  kept  at  a  temperature  between  62°  and 
65°,  the  air  moistened,  and  in  some  cases  the  addition  of  a 
little  tar  water  or  the  compound  tincture  of  benzoin  to  the 
bronchitis  kettle  is  useful.  The  temperature  of  the  patient,  if 
high,  can  be  kept  within  bounds  by  the  occasional  use  of  the 
warm  bath  (90"  to  95°),  and  the  head  may  be  sponged  with 
water,  cooler  than  this,  but  not  cold. 

The  secretions  must  be  kept  clear,  the  patient  well  supported 
by  milk,  cream,  and  properly-made  beef-tea,*  and  when 
stimulants  seem  requisite,  they  should  be  liberally  given.  In 
all  septic  cases  stimulants  are  required.  Port-wine  is  an 
excellent  stimulant,  and  may  be  combined  with  a  few  minims 
of  the  tincture  of  bark  or  with  small  doses  of  quinine,  or 
brandy  may  be  added  to  the  milk  or  broth.  Careful  support  of 
the  patient  and  good  nursing  are  of  the  utmost  importance  in 
these  cases. 

In  regard  to  drugs,  ammonia  and  ipecacuanha  are  useful 
in  loosening  expectoration,  when  this  indication  exists. 
In  cases,  on  the  other  hand,  in  which  bronchial  secretion  is 
overabundant  and  the  breathing  thereby  embarrassed,  tincture 
of  belladonna  in  two-minim  doses  every  three  or  four  hours  is 
sometimes  distinctly  helpful.  In  cases  associated  with  whoop- 
ing-cough the  spasmodic  symptoms  are  also  relieved  by  bella- 
donna, and  with  such  patients  a  few  minims  of  the  Syr.  Allii 
Aceticus  (U.S.P.)  may  be  added  to  the  mixture,  garlic'^  being 
a  remedy  of  old  standing  in  whooping-cough. 

In  the  convalescent  stage  of  the  disease  the  practitioner 
must  bear  in  mind  its  common  association  with  rickets  and  a 

*  Beef-tea  may  be  made  as  follows  :  Place  i  pound  of  lean  meat,  cut  up 
small  and  sprinkled  with  salt,  in  a  deep  dish  or  pudding-basin.  Cover 
with  I  pint  of  cold  water,  and  leave  a  couple  of  hours  near  the  fire.  After 
straining  it  will  be  ready  for  use.  The  liquid  must  not  be  boiled,  or  the 
albumin  will  be  precipitated,  and  the  nourishing  properties  of  the  beef-tea 
greatly  impaired. 


BRONCHO-PNEUMONIA  33 1 

delicate  family  history,  also  the  frequency  with  which  remnants 
of  disease  are  left  behind  in  the  lungs  or  bronchial  glands. 
Cod-liver  oil  with  steel-wine  containing  a  few  minims  of  syrup 
of  the  iodide  of  iron  are  now  valuable,  and  a  change  of  air,  to 
a  warm  seaside  place  if  possible,  is  very  important. 

Influenzal  Pneumonia. 

Before  concluding  this  chapter  we  must  make  a  more  detailed 
reference  to  the  pneumonia  which  is  so  frequent  and  serious  a 
complication  of  influenza.  In  all  epidemics  it  will  be  observed 
that  a  large  proportion  of  the  cases  are  complicated  by 
bronchial  catarrh,  sometimes  of  the  purulent  type  (see  p.  i86), 
or  even  a  broncho-alveolar  catarrh,  of  which  the  peculiar 
explosive  inspiratory  crepitation  over  one  or  both  bases  or 
scattered  patchily  over  the  lungs  is  the  most  characteristic 
sign.  This  may  clear  ofi,  but  in  many  instances  it  passes  into 
the  more  grave  condition  of  pneumonia.  In  influenza,  as  we 
have  seen,  this  is  of  the  catarrhal  type,  and  the  areas  of  con- 
soHdation,  which  in  some  cases  are  small,  in  others  large  and 
confluent,  are  set  in  a  lung  which  is  deeply  congested,  the  seat 
of  scattered  haemorrhages,  relatively  airless,  and  exuding 
blood-stained  fluid  on  section.  This  condition  of  hsemorrhagic 
cedema  is  the  most  striking  pulmonary  lesion  of  severe 
influenza,  and  may,  as  Sir  John  Rose  Bradford''  suggests,  be 
its  essential  pulmonary  manifestation,  following  the  invasion 
of  the  body  by  the  influenza  virus,  possibly  the  filter-passing 
organism  which  he,  in  conjunction  with  Drs.  Bashford  and 
Wilson,  has  described.  The  pneumonia  which  follows  would, 
on  this  view%  be  a  complication  due  to  a  secondary  infection 
by  streptococci,  pneumococci  and  Pfeiffer's  bacillus  of  in- 
fluenza, acting  upon  a  lung  already  damaged  by  the  primary 
disease.  We  must  add,  however,  that  the  bacteriology  of  the 
disease  still  remains  obscure. 

In  the  recent  epidemic  of  influenza  Drs.  Abrahams,  Norman 
Hallows,  and  Herbert  French,*  estimated  that  pulmonary 
complications  were  present  in  20  per  cent,  of  their  cases,  in 
8  per  cent,  of  which  the  complications  were  of  sHght  or  medium 
severity,  and  in  12  per  cent,  of  a  serious  nature,  one-half  to 
two-thirds  of  the  latter  proving  fatal. 

Influenzal  pneumonia  is  always  associated  with  an  asthenic 
general  condition;  nor  is  this  to  be  wondered  at  if  we  accept 


332  DISEASES    OF   THE  LUNGS   AND   PLEUR.E 

the  observations  of  Dr.  Wilson''  that  the  filter-passing  virus  is 
present  in  the  blood  from  the  early  stages  of  the  disease.  In 
other  cases  a  streptococcic  septicaemia  is  present;  less  fre- 
quently the  pneumococcus  or  Pfeiffer's  bacillus  is  discoverable 
in  the  blood.  This  general  septicaemia  more  frequently  over- 
whelms the  patient  in  the  earlier  stages  than  in  ordinary 
pneumonia,  and  exercises,  throughout  its  course,  a  baneful 
adynamic  influence.  The  local  processes,  moreover,  tend  more 
frequently  to  pass  on  in  severe  cases  to  suppurative  destruction 
of  the  lung.  The  temperature  chart,  as  a  rule,  is  wanting  in  the 
features  characteristic  of  ordinary  pneumonia,  assuming  more 
of  the  septic  type.  Drs.  Abrahams,  Norman  Hallows,  and 
Herbert  French,  have  also  noted  and  beautifully  illustrated  the 
peculiar  lividity  which  they  characterise  as  "  heliotrope 
cyanosis,"  and  the  droop  of  the  eyelids  observed  in  the  most 
grave  examples  of  the  disease,  significant  of  the  serious  blood 
changes  and  the  grave  nervous  prostration  which  are 
present.  Neither  dyspnoea  nor  undue  rapidity  of  pulse  have 
been  marked  features  of  the  malady,  but  haemoptysis,  varying 
from  a  streaking  of  the  sputum  to  several  ounces  of  pure 
blood,  has  been  of  frequent  occurrence,  and  is  no  doubt  to  be 
explained  by  the  congested  and  oedematous  condition  of  the 
lung  to  which  we  have  referred.  Epistaxis  has  also  been 
common,  as  also  some  degree  of  nephritis,  marked  by 
albuminuria  and  the  presence  of  epithelial  cells  and  tube  casts 
in  the  urine,  but  without  oedema.  The  physical  signs  in  the 
lungs  vary  with  the  severity  of  the  disease  and  the  extent  of 
the  consolidation,  and  are  not  characteristic.  Such  are  the 
more  important  features  of  influenzal  pneumonia,  which  will 
be  sufficiently  in  the  recollection  of  our  readers. 

The  perfectly  honest  frankness  with  which  Drs.  Abrahams, 
Norman  Hallows,  and  Herbert  French  confess  the  inade- 
quacy of  all  measures  to  save  the  really  desperate  cases  of 
influenzal  pneumonia  must  not  be  reg"arded  by  the  practitioner 
as  a  counsel  of  despair,  and  should  not  discourage  treatment. 
When  all  is  admitted,  it  is  but  to  confess  that  influenza 
is  a  serious  disease,  that  in  grave  epidemics  it  has  a  mortality 
of  from  6  to  8  per  cent.,  and  that  this  mortality  is  principally 
yielded  out  of  the  20  per  cent,  of  cases  with  definite  lung 
complications.     The  point  in  treatment  is  to  endeavour  to 


BRONCHO-PNEUMONIA  333 

prevent  cases  from  arriving  at  this  desperate  pass,  although 
admittedly  the  endeavour  is  sometimes  fruitless. 

The  general  lines  of  treatment  for  severe  cases  of  pneu- 
monia, as  set  forth  in  this  and  the  preceding  chapter,  hold 
good,  but  in  the  light  of  the  special  gravity  underlying  general 
infection  and  the  undoubted  contagiousness  of  this  form  of 
pneumonia,  the  following  supplementary  measures  of  treat- 
ment will  be  found  useful ; 

1.  Measures  of  Protection  and  Precaution  against  In- 
fection.— The  patient's  room  should  be  thoroughly  ventilated, 
properly  cleansed  and  kept  free  from  dust,  and  maintained  at  a 
temperature  of  55°  to  60°. 

Nursing  attendants  should  wear  masks  of  a  double  fold  of 
butter-muslin  with  a  thin  layer  of  alembroth  wool  inserted 
across  mouth  and  nose. 

The  patient's  mouth  should  be  kept  cleansed  by  the  use  of  a 
mouth-wash  several  times  a  day,  consisting  of  permanganate 
of  potash,  I  in  4,000;  or  tincture  of  iodine,  3i-  to  the  pint;  or 
solution  of  peroxide  of  hydrogen,  20  vol.,  a  teaspoonful  to  the 
half  tumbler;  or  the  compound  glycerine  of  thymol  of  the 
Pharmaceutical  codex,  diluted  with  four  or  five  parts  of  water. 
In  the  case  of  patients  too  weak  to  rinse  the  mouth,  the  gums 
and  tongue  should  be  brushed  over  with  the  solution  by  means 
of  a  camel's-hair  brush,  scalded  after  each  such  use.  Nurses 
and  attendants  should  use  similar  mouth-washes  and  gargles 
as  a  preventive. 

The  sputum  must  be  received  in  a  vessel  containing  a  dis- 
infectant. 

2.  To  combat  excessive  pyrexia  and  septicaemic  incidents 
from  5  to  10  grains  of  quinine  should  be  administered  in  a 
cocoa-butter  suppository  morning  and  evening.  If  the  patient 
should  be  very  restless,  or  the  suppositories  be  rejected, 
^  grain  of  opium  may  be  administered  with  one  or  both  the 
suppositories.  Tepid-  or  hot-water  sponging  with  eau-de- 
Cologne  should  be  employed,  and  supplementary  to  this  such 
antipyretics  as  aspirin  7  to  10  grains  in  combination  with  anti- 
pyrine,  2  grains,  may  be  given  from  tim_e  to  time  as  required. 
In  some  cases  it  is  wise  to  prescribe  considerable  doses  of 
perchloride  of  iron,  as  recommended  in  septic  pneumonia 
(PP-  302,  313). 


334  DISEASES    OF   THE   LUNGS   AND   PLEURA 

Stimulants  should  be  freely  used,  a  tablespoonful  of  brandy 
every  three,  four,  or  six  hours  as  indicated. 

Nourishing  liquid  foods  should  be  given  at  intervals  of  two 
to  three  hours,  the  stimulant  being  mixed  with  the  food  when 
convenient.  Tea  and  coffee  should  be  allowed  and  cool  drinks 
at  pleasure.  The  primae  viae  should  be  cleared,  and  a  simple 
lavement  used  from  time  to  time  to  cleanse  the  rectum  when 
rectal  medication  is  being  employed.  Probably  a  neutral 
saline  lavement  is  the  best. 

The  use  of  oxygen  is  to  be  recommended  as  an  auxiliary, 
in  cases  especially  where  the  heart  is  disposed  to  fail,  and 
sometimes  in  combination  with  subcutaneous  doses  of 
strychnia. 

REFERENCES. 

^  Diseases  of  the  Organs  of  Resfiration,  by  Samuel  West,  M.D.,  second 
edition,  vol.  i.,  p.  349.     London,  1909. 

-  "  Post-Operative  Lung  Complications,"  by  William  Pasteur,  M.D., 
F.R.C.P.,    Transactions   of   the   Medical  Society   of   London,   vol.    xxxiv., 

i9">  P-  379- 
^  (i)  "  The  Bacteriology  of  Broncho-  and  Lobular  Pneumonia  in  Infancy," 
by  Martha  Wollstein,  M.D.,  The  Journal  of  Exferimental  Medicine, 
New  York,  1901-1905  ;  vol.  vi.,  p.  391.     See  also 
(2)  The  Diseases  of  Infancy  and  Childhood,  by  L.  Emmett  Holt,  M.D., 
fourth  edition,  p.   532.     London,   1907. 

*  "  The  Bacteriology  of  Acute  Lobular  Pneumonia  and  Broncho- 
Pneumonia,"  by  J.  Eyre,  M.D.,  Allbutt  and  RoUeston's  System  of  Medicine, 
vol.  v.,  p.  175.     London,  1909. 

'  "  On  the  Bacteriology  of  Acute  Broncho-Pneumonia,"  by  P.  Horton- 
Smith  (Hartley),  M.D.,  St.  Bartholomew's  Hospital  Reports,  1897, 
vol.  xxxiii.,  p.  25. 

°  See  "  Garlic  in  'Whooping-Cough,"  by  T.  Mark  Hovell,  British  Medical 
Journal,  1916,  vol.  ii.,  p.  15.     See  also  ibid.,  p.  692. 

'  "  The   Filter-Passing   Virus   of   Influenza,"   by   John   Rose   Bradford, 

E.  F.  Bashford,  and  J.  A.  Wilson,  with  an  Appendix  of  Clinical  Notes  by 

F.  Claj^on,   the   Quarterly  Journal  of  Medicine,   vol.    12,    No.   47,   April, 

1919.  P-  259- 

^  "  A  Further  Investigation  into  Influenzo-Pneumococcal  and  Influenzo- 
Streptococcal  Septicaemia,  Epidemic  Influenzal  '  Pneumonia '  of  Highly 
Fatal  Type,  and  its  Relation  to  '  Purulent  Bronchitis,'  "  by  Adolphe 
Abrahams,  M.D.,  Norman  Hallows,  M.D.,  D.P.H.,  and  Herbert  French, 
M.D.,  F.R.C.P.,  The  Lancet,  1919,  vol.  i.,  p.  i. 


CHAPTER  XIX 

CHRONIC  INTERSTITIAL  PNEUMONIA  OR  CIRRHOSIS  OF 
THE  LUNG— PNEUMOKONIOSIS 

Interstitial  pneumonia  is  but  rarely  a  primary  disease.  The 
connective  tissue  with  which  the  lung  is  penetrated  and 
clothed,  which  sheathes  and  supports  its  vessels  and  bronchi 
and  which  holds  together  its  lobules,  necessarily  takes  part  in 
the  parenchymatous,  bronchial,  and  pleuritic  affections  of  the 
organ;  and  interstitial  pneumonia  with  but  few  exceptions  is 
only  met  with  as  a  consequence  of  bronchitis,  pleurisy,  or 
pulmonary  inflammation,  whether  tuberculous  or  otherwise, 
and  does  not  encroach  seriously  beyond  the  limits  of  the 
original  malady.  In  a  small  number  of  cases  it  has  its  origin 
from  the  deposition  in  the  lung  of  particles  of  irritating  dust — 
a  variety  of  the  disease  to  which  the  name  "pneumokoniosis" 
has  been  applied. 

Chronic  interstitial  pneumonia  is,  perhaps,  best  seen  in  con- 
nection with  bronchiectasis  or  in  cases  of  fibroid  phthisis,  but 
is  not  infrequently  a  sequel  of  broncho-pneumonia,  much  more 
rarely  of  true  lobar  pneumonia.  As  a  rule  a  considerable  area 
of  lung  is  involved,  it  may  be  the  whole  of  one  lower  lobe,  and 
sometimes  also  the  upper  lobe.  In  other  cases,  as,  for  example, 
certain  of  those  arising  from  the  inhalation  of  irritating 
particles,  the  areas  of  cirrhosis  may  be  circumscribed,  smaller, 
and  scattered  throughout  the  lungs. 

The  morbid  changes  met  with  in  pulmonary  cirrhosis  are 
fairly  uniform  in  all  cases,  and  consist  of  condensation  and 
collapse  of  the  alveoli  of  the  lung,  through  invasive  over- 
growth of  its  connective  tissue,  (a)  spreading  in  branching 
tracts  from  the  thickened  sheaths  of  the  bronchi  or  vessels 
towards  the  periphery  of  the  lung;  (b)  extending  inwards 
along  the  lobular  interstices  from  the  thickened  subpleural 
connective  tissue;  or  (c)  radiating  from  the  scar-tissue  about 

335 


336 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


some  centre  or  centres  of  retrogressive  pulmonary  lesion.  In 
the  more  rare  cases  in  which  the  affection  follows  acute  lobar 
pneumonia  resolution  has  failed  to  occur,  and  gradually  the 
affected  area  becomes  converted  into  a  dense  fibrous  mass. 

Microscopically  it  is  found  that  enormous  multiplication  of 
the  nuclei  proper  to  the  connective  tissue,  with  a  variable 
degree  of  extravasation  of  leucocytes,  constitutes  the  first 
stage.  This  is  followed  by  the  conversion  of  the  nuclear  tissue 
into  fibres  (Fig.  33),  at  first  spindle-shaped,  and  with  nuclei 
still  staining  deeply  with  carmine.  These  nucleated  fibres 
gradually  elongate  and  interlace  with  one  another  to  form 


Fig.  33. — Section  of  Lung  :  Chronic  Interstitial  Pneumonia; 
Nuclear  Proliferation  passing  into  Fibrous  Tissue. 


fibrous  tracts  or  bands  in  which  the  original  nuclei  become 
more  scarce,  and  no  longer  take  the  stain  well.  New  vessels 
are  formed,  but  in  no  great  abundance.  The  tissue  at  first, 
in  the  cellular  stages,  comparatively  soft  and  pink-looking, 
becomes  gradually  more  dense,  opaque,  pale  and  dry,  whilst 
at  the  same  time  specks  of  pigment  are  deposited,  giving  an 
ash-grey  hue  to  the  whole.  The  various  stages  of  connective- 
tissue  proliferation,  resulting  in  dense  fibrous  tissue,  can  best 
be  observed  in  pleuritic  thickening. 

Alcoholism  and  syphilis,  and  especially  alcoholism,  are  the 
conditions  peculiarly  conducive  to  the  occurrence  of  fibroid 


CHRONIC   iNTERSTITIAL   PNEUMONIA  33/ 

changes  in  the  lung",  whenever  such  changes  are  favoured  by 
the  occurrence  of  inflammatory  or  congestive  attacks. 

The  clinical  features  of  fibroid  disease  of  the  hmg  are 
necessarily  somewhat  varied.  Condensation  of  lung  texture, 
impairment  of  pulmonary  function,  and  contraction  phe- 
nomena are,  however,  essential  factors  in  the  clinical  present- 
ment of  pulmonary  fibrosis,  no  matter  whether  the  lesion  be 
seated  at  the  apex  or  base  or  in  the  central  portions  of  the 
lung,  though  they  may  be  at  times  somewhat  masked  by  the 
presence  of  compensatory  emphysema. 

Dulness  and  retraction,  with  diminished  mobility  of  the  part 
affected,  are  therefore  invariable  features.  Flattening  of  the 
chest  walls,  raising  of  the  diaphragm,  and  drawing  of  the 
mediastinum  towards  the  affected  side,  are  to  be  observed  in 
varying  degree  in  different  cases.  The  breath-sounds  are 
enfeebled,  and  their  vesicular  character  spoiled  or  altogether 
wanting.  Vocal  fremitus  is  always  diminished,  and  in  those 
cases  in  which  the  extension  is  chiefly  from  the  pleura  it  is 
more  or  less  completely  annulled.  The  contractile  changes, 
which  always  ensue  upon  pulmonary  fibrosis,  produce  more 
or  less  widening  of  the  bronchial  tubes,  especially  in  those 
cases  in  which  the  process  has  extended  either  from  the 
periphery,  or  starting  from  the  centre  has  reached  the 
periphery.  In  some  cases  these  tubes  are  so  enlarged  and 
bulbous  as  to  constitute  bronchiectatic  cavities  appreciable  to 
auscultation. 

The  symptoms  are  mostly  of  a  negative  kind — breathless- 
ness,  to  some  extent  due  to  deprivation  of  lung;  disturbed 
heart's  action,  from  the  right  ventricle  being  burdened  by  the 
increased  resistance  to  the  circulation  through  the  contracted 
lung;  and  cough,  variable  in  degree  according  to  the  presence 
or  absence  of  bronchitis,  paroxysmal  in  character,  and  often 
terminating  in  vomiting,  these  features  being  due  to  the 
mechanical  difficulty  of  clearing  mucus  from  widened  tubes 
set  in  rigid  inelastic  lung,  with  no  air-containing  lobules 
beyond  them.  Besides  these  general  characteristics  it  may  be 
said  that,  both  as  regards  symptoms  and  physical  signs,  the 
fibroid  lung  gives  but  a  modification  to  the  clinical  features 
of  those  diseases,  such  as  chronic  bronchitis,  pleuritis,  pneu- 
monia, bronchiectasis,  etc.,  of  which  it  may  form  a  part,  and 
to  some  one  of  which  it  is  generally  to  be  ascribed. 

22 


338  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

In  diagnosis  the  fibroid  lung  is  to  be  differentiated  from 
more  active  lesions,  but,  except  in  the  case  of  local  empyema, 
difficulty  seldom  arises,  and  here  it  can,  as  a  rule,  be  cleared 
up  by  exploratory  puncture.  It  sometimes,  but  rarely, 
happens  that  a  bronchus  becomes  entangled  in  the  contractile 
fibroid  lesion,  giving  rise  to  signs  and  symptoms  suggestive 
of  aneurism  or  malignant  disease  compressing  the  tubes. 

Pneumokoniosis. 

Before  leaving  the  subject  of  chronic  interstitial  pneumonia, 
that  somewhat  rare  variety  must  be  referred  to  which  results 
from  the  inhalation  of  certain  forms  of  irritating  dust,  and  to 
which  the  name  "  pneumo-  or  pneumonokoniosis  "  has  been 
appHed.^ 

When  speaking  of  bronchitis,  we  saw  that  it  might  some- 
times be  traced  to  a  similar  cause,  and  we  have  described 
(p.  264)  a  case  of  dust-bronchitis,  with  asthma  and  em.physema, 
which  illustrated  the  form  of  disease  most  commonly  met  with 
amongst  those  engaged  in  dusty  employments.  In  certain 
cases,  however,  after  the  bronchitis  has  persisted  for  some 
time,  and  the  ciliated  epithelium  has  thereby  become  damaged 
and  its  functions  impaired,  the  dust  particles  find  their  way 
past  the  bronchi  into  the  alveoli  of  the  lung.  Thence  they  pass 
between  the  cells  lining  the  air-vesicles,  and  so  into  the  lymph 
channels  and  connective-tissue  spaces  of  the  alveolar  walls. 
Here  irritation  is  set  up,  leading  to  the  formation  of  fibroid 
material,  which  at  first  thickens  the  walls  of  the  air-spaces,  and 
later  produces  fibroid  nodules  or  bands  of  various  size  (Plates 
XVI.  and  XVII.).  These  may  again  unite,  until  a  large  portion 
of  a  lobe,  or  indeed  a  whole  lobe,  may  become  consolidated. 

The  various  kinds  of  dust  differ  much  in  their  irritative 
properties,  though  their  effects  upon  the  lung,  when  ultimately 
produced,  are  pathologically  of  a  similar  nature.  Coal  dust  is 
comparatively  innocuous,  and  cases  of  true  anthracosis,  with 
fibroid  changes  in  the  lungs,  are  now  rare,  and  even  when 
met  with  it  is  probable  that  the  fibrous  changes  are  due  to  the 
stone  dust  from  the  strata  in  which  the  coal  is  embedded 
rather  than  to  the  coal  dust  itself.  In  these  patients  the 
expectoration  is  often  highly  charged  with  carbon,  and  is 
spoken  of  by  the  miners  as  "  black  spit."    A  simple  discolora- 


■irfj  ni  f)3>lTf, 

':  <^  y  -' 
I    ■■...(, 


PLATE  XV r 


jbon  fan£ 


PNEUMOKONIOSIS 

The  drawing  represents  a  portion  of  a  left  lung  which  shows 
the  effect  of  the  inhalation  of  irritating  particles.  The  lung  is 
denser  and  firmer  than  natural,  as  the  result  of  diffuse  fibrosis, 
and  nodules  of  dense  fibrous  tissue  having  a  bluish-black  colour 
are  seen  scattered  throughout  it,  but  mostly  in  the  upper  lobe. 
Many  of  these  nodules  are  separate  and  discrete,  as  at  A  ;  but 
at  the  lower  part  of  the  upper  lobe  they  have  coalesced  into  a 
large  mass,  B.  No  tuberculous  lesions  were  found  in  the  lung. 
The  pleura  is  not  thickened.  On  microscopical  examination  the 
general  diffused  fibrosis  was  found  to  be  especially  marked  in  the 
neighbourhood  of  the  bronchi. 

From  a  man  aged  forty-nine,  who  was  engaged  in  the  Sheffield 
cutlery  trade,  and  who  died  of  cerebral  hiemorrhage. 


(Fioni   the   Museum  of   St.    Bartholomew's   Hospital.     2   natural 

size.) 


PLATE  XVI 


Pneumokoniosis. 


To  face  p.  338. 


CHRONIC   INTERSTITIAL   PNEUMONIA  339 

tion  of  the  lungs  from  deposition  in  them  of  particles  of  carbon 
is,  however,  extremely  common  in  those  who  work  in  coal,  as, 
indeed,  it  is  to  some  degree  in  all  who  live  in  large  and  smoky- 
cities.  Calmette"  and  his  pupils  have  contended  that  such 
staining  is  produced,  not  by  direct  inhalation,  but  by  absorp- 
tion  from   the    alimentary   canal    of   ingested   carbonaceous 


O 

0     ^ 


eS" 

Q 

\ 

0 

0 

^ 

0 

<> 

0 

0 

o 


Fig.  34.— Drawing  showing  Larger  Particles  of  Silica  isolated  from 
A  Silicotic  Lung,  x  1,000.  The  Line  below  represents  10  ^,  the 
Circle  a  Red  Blood-Corpuscle. 

(After  Dr.  John  McCrae.*) 

particles,  but  his  work  has  not  been  confirmed  by  recent 
observers,^  and  we  may  confidently  adhere  to  the  old  respi- 
ratory theory  as  to  the  origin  of  anthracosis  and,  a  priori,  of 
other  forms  of  pneumonokoniosis. 

A  much  more  dangerous  form  of  dust  is  that  consisting  of 
fine  particles  of  silica,  which  from  its  insolubility  and  the 
pointed  and  angular  character  of  its  particles,  which  are  to  be 


340  DISEASES    OF   THE   LUNGS   AND   PLEURA 

found  in  situ  in  the  lungs  (see  Fig.  34)  is  peculiarly  irritating. 
To  the  resulting  pneumokoniosis  the  name  silicosis  has  been 
applied.  Silica  is  met  with  geologically  as  quartz,  quartzite, 
and  flint,  and  siliceous  dust  is  thus  set  free  in  the  blasting  and 
drilling  carried  on  in  the  quartzite  gold-mines  of  South  Africa, 
giving  rise  to  the  disease  known  as  "gold-miner's  phthisis."^' 
Silicosis  is  also  met  with  among  stonemasons,  mill-stone 
builders,  and  potters,  and  among  those  working  with  ganister* 
(Plate  XVII.),  a  hard  quartzite  rock  used  on  account  of  its 
"great  resistance  to  heat  for  lining  Bessemer  and  steel  con- 
verters in  ironworks"  (Oliver).^'^ 

Particles  of  iron  may  occasionally  produce  similar  changes 
in  the  lung  tissues,  but  such  cases  of  siderosis,  as  they  are 
called,  are  not  common.  In  the  various  forms  of  steel  grinding 
it  is  the  dust  from  the  grindstone  rather  than  from  the  steel  in 
which  the  danger  lies  (Plate  XVI.).  In  true  siderosis  the  lung 
tissue  may  be  of  a  reddish-yellow  colour,  from  the  deposition 
of  peroxide  of  iron. 

Such  are  the  more  important  conditions  under  which 
pneumokoniosis  occurs,  and  it  is  satisfactory  to  know  that  it 
is  decidedly  less  frequent  now  than  in  former  years,  owing  to 
the  precautions  which  are  being  taken  by  wet-grinding, 
exhaust  fans,  and  similar  expedients,  to  protect  the  workman 
from  the  baleful  influence  of  the  dust. 

^'ym/'^om^.— Pneumokoniosis  is  generally  insidious  in  its 
onset.  A  cough  developes  and  the  breath  becomes  short,  but 
there  is  little  wasting  and  no  night-sweating,  and  constitu- 
tional symptoms  are  not  marked.  The  signs,  in  fact,  are  those 
of  bronchitis  and  emphysema,  with  which  the  disease  is 
generally  complicated.  Provided  that  the  fibroid  areas  are 
small  and  scattered,  as  in  the  variety  described  as  "  generalised 
nodular  fibrosis,"  there  may  be  no  impairment  of  note  and  no 
alteration  of  breathing.  The  emphysema  may,  in  fact,  mask 
the  disease.  An  X-ray  examination  will,  however,  in  many 
cases  show  clearly  defined  mottling  (Plate  XVIII.),  the 
shadows  being  more  sharply  defined  and  deeper  than  those 
observed  in  pulmonary  tuberculosis,  in  which  the  mottling  has 
a  somewhat  hazy  and  blurred  appearance. 

Later,  when  larger  areas  of  fibrosis  have  developed,  the 
signs  which  we  have  already  described  at  the  beginning  of  this 
chapter  as  significant  of  this  condition — dulness,  retraction 


PLATE   XVTI 


PNEUMOKONIOSIS  (SILICOSIS)  COMPLICATED  BY 

TUBERCLE 

The  drawing  shows  the  lung  tissue  to  be  much  firmer  than 
natural,  as  the  result  of  diffuse  fibrosis,  which  on  microscopical 
examination  was  seen  to  commence  around  the  bronchioles.  In 
addition,  numerous  sharpty-defined,  hard,  greyish-blue  fibrous 
nodules,  about  a  quarter  of  an  inch  in  diameter  (B),  are  seen 
scattered  through  the  lung.  Upon  these  lesions  tubercle  appeared 
to  have  become  engrafted,  and  at  A.  near  the  base  of  the  upper 
lobe,  a  large  tuberculous  cavity  is  found.  At  the  apex  of  the 
lung  smaller  foci  of  tuberculous  disease  are  visible. 

From  a  ganister  miner,  who  had  suffered  for  many  years  from 
fibroid  disease  of  the  lung,  and  who  for  some  time  had  been 
unable  to  follow  his  occupation.  Death  resulted  from  empyema 
and  acute  pericarditis  of  pneumococcal  origin. 


(From  the  Museum  of   St.   Bartholomew's  Hospital,     j^  natural 

size.) 


PLATE  XVII 


Pneumokoniosis  (Silicosis)  complicated  by  Tubercle. 


To  face  p.  340. 


CHRONIC   INTERSTITIAL   PNEUMONIA  341 

with  diminished  mobility  of  the  affected  side,  and  so  forth — 
will  make  their  appearance.  If  the  patient  continues  at  his 
work,  the  disease  gradually  progresses,  bronchial  dilatation  is 
apt  to  ensue,  and  death  results,  often  from  an  intercurrent 
attack  of  acute  bronchitis  or  pneumonia.  The  duration,  how- 
ever, varies  with  the  nature  and  amount  of  the  dust  inhaled. 
Thus  Dr.  Oliver  places  the  duration  of  life  after  commence- 
ment of  symptoms  at  from  five  to  six  years  among  the  rock- 
drillers  in  the  South  African  gold-fields,  and  at  about  fifteen 
years  among  steel-gTinders,  while  coal-miners  live  still  longer. 
It  has  been  found  in  South  Africa  that  if  in  the  early  stages 
of  the  disease  the  miner  gives  up  his  underground  occupation 
and  takes  to  open-air  work,  arrest  of  the  malady  and  great 
improvement  in  the  general  health  not  uncommonly  results. 

In  not  a  few  cases  the  disease  terminates  earlier,  owing  to 
infection  by  the  tubercle  bacillus,  the  tuberculous  disease  in 
these  cases  running  its  course  with  the  formation  of  cavities, 
although  the  fibroid  features  still  remain  (Plat§  XVII.). 

It  is,  perhaps,  unnecessary  to  add  that  pulmonary  tubercu- 
losis of  an  ordinary  type  is  frequently  developed  in  young 
operatives  in  dusty  factories,  and  especially  among  those  in 
whom  there  is  a  family  predisposition.  In  such  the  dusty 
atmosphere  and  confinement  in  ill-ventilated  rooms  strongly 
favour  the  development  of  the  malady.  These  cases  do  not 
present  any  unusual  features. 

In  conclusion,  we  may  give  the  notes  of  the  following  case, 
which  illustrates  certain  of  the  features  of  this  interesting 
malady : 

A.  H.  H.,  gold-miner  in  South  Africa,  aged  thirty-two,  single,  was 
admitted  into  the  Brompton  Hospital  under  the  care  of  one  of  us  in 
April,  1915.  He  came  of  healthy  parentage,  there  being  no  history 
of  tuberculosis  in  the  family,  and  his  own  health  in  the  past  had 
been  good. 

In  1902  he  commenced  work  as  a  "  driller  "  in  the  gold-mines  near 
Johannesburg,  his  place  being  at  the  "  dead  end  "  of  the  mine  gallery, 
where  exposure  to  dust  was  greatest.  All  went  well  with  him  for 
8-1  years,  when  he  began  to  suffer  from  shortness  of  breath  and  cough. 
These  symptoms  increased,  and  at  one  time  kept  him  away  from  work 
for  two  months.  Expectoration  had  never  been  more  than  slight  in 
amount.  He  coptinued  at  his  occupation  until  March,  1914,  when  he 
gave  it  up  and  came  to  England.  Since  his  arrival  he  had  lived  in 
Kilburn,  residing  at  home,  but  doing  no  work.     His  cough,  however, 


342  DISEASES    OF   THE  LUNGS   AND   PLEURA 

became  worse,  and  a  year  later  (April,  1915)  he  entered  the  Brompton 
Hospital. 

On  admission  he  was  found  to  be  a  man  of  somewhat  poor  physique. 
Height  5  feet  9  inches,  weight  10  stone  2J  pounds.  He  was  short  of 
breath  on  exertion,  the  respirations  even  at  rest  being  generally  over  20. 
Pulse  84 ;  temperature  normal.  His  cough  was  very  troublesome,  and 
he  suffered  from  time  to  time  from  bouts  of  coughing  lasting  perhaps 
half  an  hour.  The  phlegm  was  scanty  and  viscid,  and  difficult  to 
expectorate.  Tubercle  bacilli  were  never  found,  though  the  sputum 
was  examined  on  four  occasions  at  the  hospital,  once  by  the  antiformin 
method. 

On  physical  examination,  no  marked  signs  of  emphysema  were 
apparent,  and  the  heart  was  natural.  The  air-entry  over  the  front  of 
the  chest  was  satisfactory,  but  at  the  back  the  percussion  note  over  the 
base  of  each  lung  was  somewhat  impaired,  the  vocal  vibrations 
increased,  the  respiratory  murmur  weak,  and  numerous  small  rales 
were  audible  after  coughing.  On  the  left  side  these  signs  extended  to 
the  mid-scapular  region.    The  fingers  were  not  clubbed. 

The  patient  was  examined  by  Dr.  Melville  under  the  X-rays,  and 
the  characteristic  findings  are  shown  in  Plate  XVHI.  The  upper  parts 
of  the  lungs  are  seen  to  be  fairly  free  from  disease,  but  in  the 
lower  two-thirds  numerous  small  discrete,  sharply-defined,  and  rounded 
shadows  are  seen,  with,  in  places,  larger  and  darker  areas  of  shading, 
the  former  corresponding  to  scattered  areas  of  nodular  fibrosis,  the 
latter  to  more  extensive  changes  of  a  similar  nature. 

The  patient  stayed  nearly  two  months  in  the  hospital,  and  then 
returned  home.  He  had  no  pyrexia,  and  gained  4  pounds  in  weight, 
and,  on  leaving,  his  cough  was  somewhat  easier,  and  the  moist  sounds 
at  the  right  base  were  fewer  in  number.  Otherwise  his  condition  was 
not  materially  changed. 

In  September  he  went  to  Eastbourne,  and  a  month  later  was 
taken  ill  in  a  picture  palace.  He  returned  to  London  at  the  end  of 
October,  and  died  on  November  12th,  1915,  of  bronchitis  and  heart 
failure,  the  end  being  preceded  by  distressing  attacks  of  dyspnoea. 

This  case  shows  the  long  period — in  this  case  more  than 
eight  years — w^hich  may  elapse  before  symptoms  of  pneu- 
mokoniosis  manifest  themselves,  in  spite  of  continued  ex- 
posure to  the  baleful  influence  of  the  dust.  The  characteristic 
X-ray  appearances  and  the  chronic  nature  of  the  malady,  with 
fair  retention  of  general  health,  are  also  demonstrated. 

REFERENCES. 

'  In  regard  to  the  subject  of  pneumonokoniosis,  reference  should  be 
made  to  : 

(a)  Diseases  of  Occufation,  by  Thomas  Oliver,  M.D.,  F.R.C.P.,  p.  298. 
London,   190S.     Also — 


PLATE  XVIII 


X-Ray  Api'earances  in  a  Case  of  Gold-Miner's  Phthisis  of  Medium  Severity, 
SHOWING  Numerous  Small  Discrete  and  Rounded  Shadows,  with,  in 
Places,  Larger  and  Darker  Areas  of  Shading,  the  Former  corresponding 
to  Scattered  Areas  of  Nodular  Fibrosis  in  the  Lungs,  the  Latter  to 
More  Extensive  Changes  of  Similar  Nature. 

(From  the  case  of  A.  H.  H.,  recorded  in  the  text.) 


To  face  p.  342. 


CHRONIC   INTERSTITIAL   PNEUMONIA  343 

(b)  "  The  Etiology  and  Prevention  of  Pneumonokoniosis,"  by  Thomas 
Oliver,  M.D.,  being  a  contribution  to  "  A  Discussion  on  Diseases 
of  the  Lungs  caused  by  Dust,"  British  Medical  Journal,  1908,  vol.  ii., 
p.  481. 

(c)  The  late  Dr.  Greenhow's  original  investigations  into  the  subject 
published  in  [a)  Public  Health  Re-ports  for  1860-61 ;  (6)  the  Transac- 
tions of  the  Pathological  Society  of  London,  vols,  xvi.,  xvii.,  xx., 
and  xxi.  Many  of  Dr.  Greenhow's  specimens  will  be  found  in  the 
Museum  of  the  Middlesex  Hospital. 

(d)  "  The  Hygienic  Aspect  of  the  Coal-Mining  Industry  in  the  United 
Kingdom,"  Milroy  Lectures,  1914,  by  Frank  Shuffiebotham,  M.A., 
M.D.,  The  Lancet,  1914,  i.,  pp.  1731,  1799- 

{e)  "  Industrial  Pneumonoconioses,  with  Special  Reference  to  Dust 
Phthisis,"  by  Edgar  L.  Collis,  M.B.  (Oxon),  Milroy  Lectures,  1915, 
reprinted  from  Public  Health. 

^  For  an  interesting  account  of  Calmette's  experiments,  see  the  Caven- 
dish Lecture  on  "  The  Etiology  of  Pulmonary  Tuberculosis,"  by  Sir 
William  Whitla,  M.D.,  LL.D.,  British  Medical  Journal,  1908,  vol.  ii.,  p.  61. 

^  The  Causes  of  Tuberculosis,  by  Louis  Cobbett,  M.D.,  F.R.C.S., 
pp.    142-151.     Cambridge,    1917. 

"  "  The  Ash  of  Silicotic  Lungs,"  by  John  McCrae,  Ph.D.,  F.I.C.,  South 
African  Institute  for  Medical  Research,  Johannesburg,  1913. 

"  See  [a)  "  Miner's  Phthisis  :  Recent  Investigations,"  by  Drs.  Watt, 
Irvine,  Johnson,  and  Steuart,  The  Medical  Journal  of  South 
Africa,  vol.   xi.,    1916,   pp.    i,    15. 

{b)  "  Silicosis  (Miner's  Phthisis)  on  the  Witwatersrand,"  by  the 
same  authors.  Pretoria,  1916;  and  a  review  thereof  in  the 
British  Medical  Journal,   1916,   vil.   ii.,  p.  653. 

°  "  Report  on  Portions  of  Lung  from  a  Ganister  Miner,"  by  F.  W. 
Andrewes,  M.D.,  F.R.C.P.,  Annual  Report  of  the  Chief  Inspector  of 
Factories  and  Workshops  for  the  Y ear  1900,  p.  487.     London,  1901, 


CHAPTER  XX 

COLLAPSE  OF  THE  LUNG— MASSIVE  COLLAPSE 

We  have  pointed  out  (p.  203)  that  in  cases  of  stenosis  of  a 
bronchus,  collapse  of  the  lung  to  which  it  is  tributary  is  apt  to 
follow,  the  mechanism  being  that,  as  secretions  accumulate 
behind  the  obstruction,  air  can  no  longer  penetrate  to  the 
lung-,  whilst  what  remains  is  expelled  or  absorbed.  In 
bronchitis  and  in  broncho-pneumonia  in  weakly  persons  and 
in  children,  whose  chest-walls  are  lax  or  wanting  in  muscular 
support,  collapse  of  lobules  of  the  lung  is  frequently  to  be 
observed.  Mucous  collection  in  the  tubes,  whilst  permitting 
air  to  escape,  is  obstructive  to  its  entry  to  the  lobules,  which 
thus  gradually  become  deflated.  In  whooping-cough  in  young 
children,  attended  with  bronchitis  or  broncho-pneumonia, 
scattered  collapse  of  the  lung  having  this  mechanism  is  one 
of  the  most  dreaded  complications,  and  is  one  of  the  causes  of 
the  broncho-pneumonic  centres  so  frequently  attendant  upon 
the  disease. 

Collapse  of  the  lung  from  external  pressure,  such  as  from 
effusion  into  the  pleura,  of  whatever  kind,  is  more  accurately 
spoken  of  as  compression  of  the  lung,  although  in  the 
earlier  stages  the  lung  recedes  before  the  effusion  by 
virtue  of  its  elasticity,  and  only  later  begins  to  be  com- 
pressed. Intrathoracic  growths  may  cause  collapse  and  com- 
pression of  the  lung  directly,  or  by  partial  occlusion  of  the 
bronchi  may  produce  first  collapse  and  compression,  and 
secondly  fibrosis  and  even  disorganisation  of  the  lung, 
especially  in  cases  in  which  the  vessels  or  nerves  are  involved. 
In  pleuritic  cases  the  pleura  may  become  thickened  and  may 
bind  down  the  collapsed  lung.  Still  further  changes  may 
result  in  bronchiectasis  or  bronchiectatic  cavitation  of  the 
lung.     These  conditions  have  been  sufficiently  alluded  to  in 

3^1 


COLLAPSE   OF   THE   LUNG  345 

connection  with  the  diseases  in  which  they  occur,  and  require 
no  further  mention  here. 


Massive  Collapse  of  the  Lung. 

There  is  another  form  of  collapse  of  the  lung  which  has  an 
entirely  different,  perhaps  more  than  one,  origin,  and  which  is 
most  probably  due  to  paretic  failure  of  the  inspiratory  power 
of  the  chest-wall  on  one  or  both  sides.  "Massive"  or  lobar 
collapse  of  the  lung  has  been  defined  by  Dr.  Pasteur,^  who 
first  described  the  condition,  as  a  total  deflation  of  a  large  area 
of  lung-tissue  of  sudden  onset,  due  to  failure  of  inspiratory 
power,  and  attended  by  definite  physical  signs  and  symptoms. 
After  referring  to  the  papers  of  Professor  Keith,  1903,  and 
Dr.  Halls  Dally,  1908,  on  the  mechanism  of  respiration,  he 
draws  the  conclusion  that  "  expansion  of  the  lungs  takes  place 
under  the  influence  of  two  forces,  costal  and  diaphragmatic, 
and  that  the  overlapping  between  their  two  spheres  of  action 
roughly  corresponds  to  the  position  of  the  great  fissure,  the 
costal  force  acting  mainly  above  and  the  diaphragmatic  force 
mainly  below  it."  Massive  collapse  is  always  attendant  upon 
serious  failure  of  inspiratory  power,  and  there  are  two  well- 
defined  varieties — namely,  (i)  Cases  in  which  collapse  is  due  to 
paralysis  of  the  essential  muscles  of  inspiration,  and  is  a  local 
result  of  a  general  motor  failure,  as  in  diphtheritic  or  in  ascend- 
ing paralysis.  In  these  cases  the  collapse  is  more  or  less  sym- 
metrically bilateral.  (2)  Cases  in  which  the  collapse  supervenes 
suddenly  without  any  general  cause,  and  in  which  it  has 
apparently  a  reflex  origin,  being  traceable  to  some  shock  or 
injury  to  the  thoracic  wall,  or  to  some  more  distant  part.  In 
this  class  the  cases  are  for  the  most  part  unilateral.  Thus  the 
paralysis  of  the  respiratory  motor  mechanism  in  massive 
collapse  of  the  lung  may  be  of  direct  or  reflex  (inhibitory) 
causation. 

Group  I. — This  group  of  cases  includes  those  first  ob- 
served by  Dr.  Pasteur  in  connection  with  post-diphtheritic 
paralysis,  principally  in  children,  in  which  the  paralysis  in- 
volved the  diaphragm.  In  these  cases  the  lungs  gradually 
collapse  towards  the  foetal  position,  and  unless  nervous  power 
is  speedilyrestored  to  the  inspiratory  muscles,  death  ensues.  In 
such  cases  the  deflation  is  more  or  less  symmetrical,  affecting 


346  DISEASES   OF   THE   LUNGS   AND   PLEURA 

the  bases  of  the  lungs,  but  may  involve  almost  the  whole  of 
one  or  both  lungs.  The  physical  signs,  owing  to  the  general 
condition  of  the  patient,  are  difficult  to  investigate  with 
accuracy,  and  the  consolidation,  with  its  signs  of  feeble  or 
annulled  breath-sounds  and  variable  rales,  is  commonly  attrib- 
uted to  pneumonia,  broncho-pneumonia,  or  pleuritic  effusion. 
Pyrexial  symptoms  are,  as  a  rule,  irregular ;  they  may  be  want- 
ing, and  are  never  very  marked.  A  notable  recession  of  the 
chest-wall  may  be  observed,  whilst  the  arch  of  the  diaphragm 
is  raised,  the  cardiac  area  being  likewise  displaced  upwards. 
The  condition  of  the  patient  is  that  of  general  failure,  and 
death  may  arise  from  apnoea  or  syncope.  In  some  cases,  how- 
ever, the  respiratory  muscles  recover  their  action,  and  rapid 
improvement  follows  the  restoration  of  the  pulmonary 
function. 

Group  II. — The  interest  of  the  cases  just  described  lies  in 
the  fact  that  their  observation  led  Dr.  Pasteur  to  the  investi- 
gation of  other  cases  of  collapse  of  the  lung,  of  the  second 
group,  of  greater  importance,  and  the  interpretation  of  which 
is  more  difficult.^*  In  these  cases,  which  attracted  much  atten- 
tion in  connection  with  gunshot  wounds  in  the  recent  war, 
and  to  which  we  have  referred  in  Chapter  X.,  collapse  of 
the  lung  follows  upon  an  injury,  it  may  be  to  a  distant  part,  or 
to  some  portion  of  the  chest-wall  not  necessarily  connected 
with  or  even  on  the  same  side  as  the  portion  of  lung  affected. 
If  on  the  same  side  as  the  injury  to  the  chest,  the  condition  is 
spoken  of  as  "homolateral  collapse";  if  on  the  opposite  side, 
as  "  contralateral."  In  other  cases  the  collapse  has  followed 
abdominal  operations.  The  collapse  may  be  associated  with 
such  conditions  as  pleurisy,  or  be  complicated  with  embolism 
or  haemothorax  of  the  same  or  opposite  side,  or  may  pass  on 
to  some  form  of  pneumonia;  but  these  are  compHcations  upon 
which  we  need  not  in  the  present  place  dwell  further. 

Clinical  Features. — Being  commonly  one-sided,  the  physical 
signs  are  more  striking  and  conclusive  than  in  the  previous 
group  of  cases.  There  is  flattening  and  diminution  in  size  of 
the  chest  on  the  side  affected,  with  depression  rather  than 
expansion  during  inspiration;  the  arch  of  the  diaphragm  is 
raised,  and  the  heart  displaced  towards  the  affected  side, 
unless,  as  in  some  traumatic  cases,  direct  injury  has  caused  an 
effusion    of   fluid    on    this    side.     The    respiratory    murmur. 


COLLAPSE   OF   THE  LUNG  347 

at  first  weakened  over  the  affected  area,  becomes  more 
or  less  intensely  bronchial,  and  is  attended  with  crepitations 
and  later  with  large  mucous  or  even  gurgling-  rales.  On 
the  opposite  side  the  movements  of  inspiration  are  increased, 
the  resonance  extends  beyond  the  normal  confines  towards  the 
middle  line,  and  the  breath-sounds  are  exaggerated. 

The  collapse  of  the  lung  supervenes  within  twenty-four 
or  forty-eight  hours  of  the  injury.  Dyspnoea,  variable  in 
degree,  sometimes  very  urgent,  is  the  first  symptom,  and  in 
severe  cases  is  accompanied  by  more  or  less  shock.  The 
temperature  usually  rises  within  a  few  hours  to  ioo°,  or 
even  to  102°  or  103°,  but  is  of  no  characteristic  type.  There  is 
a  short  cough,  rather  persistent,  at  first  dry,  afterwards 
attended  with  a  viscid,  clear,  mucoid  expectoration,  later 
becoming  more  abundant  and  muco-purulent  in  character. 
Haemoptysis  is  unusual,  and  Dr.  Pasteur  states  that  it  never 
occurs  in  pure  massive  collapse.  Sir  John  Rose  Bradford- 
found  it  a  more  frequent  symptom  in  his  cases,  w^hich  were, 
however,  mostly  secondary  to  gunshot  injury  of  the  chest- 
wall,  in  the  phenomena  of  which  massive  collapse  is,  in  his 
experience,  a  frequent  and  an  important  factor.  In  favour^ 
able  cases  of  reflex  origin,  as  in  those  of  central  origin 
in  which  nerve  function  is  restored,  the  symptoms  gradually 
abate  and  disappear.  When  fatal,  death  is  usually  due  to  the 
primary  nerve  cause  of  the  collapse,  or  to  complications. 

etiology. — It  must  be  admitted  that  it  is  rather  assumed 
than  actually  proved  that  paralysis  of  the  inspiratory  muscles, 
either  as  a  part  of  some  general  paralysis  or  of  reflex  inhibitory 
origin,  is  the  primary  cause  of  massive  collapse  of  the  lung. 
The  cases  which  originally  attracted  Dr.  Pasteur's  attention 
were,  as  we  have  seen,  those  attendant  upon  diphtheritic 
paralysis;  they  were  mostly  bilateral  or  symmetrical,  and 
would  seem  to  be  of  paralytic  origin.  The  unilateral  cases, 
occurring  as  they  do  as  sequels  of  such  lesions  as  surgical 
operations  for  appendicitis,  hernia,  salpingectomy  or  chole- 
cystectomy (Pasteur)^*;  or  after  such  injuries  as  gunshot 
wounds,  not  necessarily  penetrating,  of  the  thoracic  or 
abdominal  wall,  or,  as  recorded  by  Sir  John  Rose  Bradford,  of 
the  pelvis  or  thigh,  appear  to  admit  no  other  possible  aetiology 
than  that  of  a  reflex  nervous  inhibition,  the  precise  route  of 
which  requires,  however,  further  observation  to  elucidate. 


348  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Mechanism. — The  pathology  of  the  disease  consists  essen- 
tially of  an  airless  collapse  of  the  lung,  which  may  involve 
the  whole  of  one  lobe  or  even  the  entire  lung,  or  it  may  affect 
considerable  portions  of  both  lungs.  Various  explanations 
of  the  mechanism  by  which  this  collapse  is  brought  about 
have  been  suggested.  Of  these,  expiratory  deflation  and 
bronchial  contraction,  with  absorption  of  air  from  the 
alveoli,  are  the  chief.*  Assuming  the  primary  cause  of  massive 
collapse  to  be  a  paralysis  of  the  inspiratory  muscles,  and  more 
particularly  of  the  diaphragm,  the  mechanism  of  its  occurrence 
does  not  seem  difficult  of  comprehension.  The  condition  of 
the  lung  would  rapidly  be  reduced  to  that  of  complete  de- 
flation, as  shown  in  five  of  Dr.  Pasteur^s  eight  cases  in  which 
an  autopsy  was  made,  and  in  the  following  manner:  (i)  The 
chest-walls,  being  paralysed,  would  fall  in  towards  the  foetal 
position,  following  the  lung,  which  (2)  would  collapse  to  the 
position  of  elastic  quiescence;  (3)  the  respiratory  efforts 
consequent  upon  the  need  of  air  would  result  in  increased 
expansile  movements  of  the  unaffected  side.  This  would  have 
two  effects — (a)  Atmospheric  pressure  would  bear  on  all  sides, 
thoracic,  diaphragmatic,  and  mediastinal,  tending  to  produce 
more  complete  collapse  of  the  affected  lung;  (b)  the  forcible 
expansion  of  the  sound  side  of  the  thoracic  cavity,  whilst 
drawing  extra  air  in  through  the  main  bronchus  proper  to  that 
lung,  would  also  aspirate  air  from  the  bronchus  of  the  affected 
lung,  and  thus  any  residual  air  would  be  gradually  but  rapidly 
removed. 

The  mechanism  of  the  second  clinical  feature  of  massive 
collapse — namely,  displacement  of  the  heart  to  the  affected  side 
(in  one-sided  cases  unaccompanied  with  effusion) — is  also 
readily  explained.  The  same  mechanism  by  which  the  chest  is 
retracted  and  the  lung  collapsed  must  necessarily  tend  to  draw 
the  heart  over  to  the  affected  side.  As  a  clinical  feature  this 
displacement  appears  somewhat  exaggerated,  being  in  part 
apparent  and  relative  only,  inasmuch  as  (a)  the  thoracic 
cavity  on  the  affected  side  is  diminished  and  its  walls  approxi- 
mated towards  the  median  line  :  hence  the  margin  of  the  chest- 
wall  and  line  of  the  nipple  are  approximated  to  the  correspond- 
ing side  of  the  heart;  (b)  the  heart  is  also  uncovered  by  the 

*  For  a  full  discussion  of  the  mechanism  of  this  form  of  lung  collapse 
reference  should  be  made  to  Sir  John  Rose  Bradford's  paper,'  and  to  a 
inore  recent  paper  by  Dr.  J.  Charlton  Briscoe." 


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MASSIVE    COLLAPSE    OF    THE    LUNG,  WITH    CARDIAC 

DISPLACEMENT 

A  glance  at  the  plate,  which  is  taken  in  outline  from  Sir  J.  Rose 
Bradford's  paper^,  illustrates  the  approximation  of  the  chest  wall  on 
the  side  affected  to  the  median  line  ;  the  uncovering  of  the  heart  on 
this  side  and  its  overlapping  by  lung  on  the  sound  side  ;  the 
total  effect  being  to  exaggerate  the  shifting  of  the  heart  to 
the  affected  (left)  side.  The  details  are  added  to  the  original 
photograph. 

A,  heart  in  dark  shadow. 

B,  lighter  shadow  fading  to  right  (overlapping  lung). 
B',  darker  than  B.  but  less  so  than  A. 

C. C,  diaphragm. 

Measurement  i — 2  =  2 '25  inches. 
I— 2'=  2-6 

"  "       ■   opposite  second  cartilage. 

3-4'- 2-5        ,.      \      ^^ 

The  left  nipple,  not  marked  in  the  original  plate,  is  hypothetically 
placed  lower  and  nearer  the  median  line  in  accordance  with  shrink- 
ing of  the  chest  on  this  side. 


PLATE  XIX 


COLLAPSE  OF  THE  LUNG  349 

withdrawal  of  the  margin  of  the  collapsed  lung;  (c)  on  the 
other  side  the  heart's  area  is  overlapped  by  the  encroachment 
of  the  sound  lung,  A  reference  to  the  second  and  third  radio- 
graphic illustrations  of  Sir  John  Rose  Bradford's  paper,  and 
especially  the  third,  which  we  reproduce  (Plate  XIX),  shows 
this  well. 

How  far  bronchial  contraction,  of  reflex  origin,  may  be 
concerned  in  the  production  of  some  cases  of  massive  collapse 
secondary  to  gunshot  injury  of  the  chest-wall  it  would  be 
difficult  to  say.  Colonel  Elliott*  appears  to  attach  considerable 
importance  to  it  as  a  cause  of  asphyxiative  dyspnoea  following 
upon  injury.  We  should  regard  it  as  a  separate  condition  from 
massive  collapse,  seeing"  that  in  asthma,  the  most  striking 
clinical  result  of  bronchial  spasm,  we  witness  not  collapse, 
but  expiratory  dyspnoea  and  overdistension  of  the  lung 
vesicles.  In  the  local  collapse  of  a  portion  of  the  lung,  due 
to  the  occlusion  of  the  middle  division  of  the  bronchus  supply- 
ing the  lower  lobe,  which  is  described  by  Colonel  Elliott,  the 
mechanism  is  separate  and  distinct  from  that  of  massive  col- 
lapse and  requires  no  further  comment. 

Dr.  Charlton  Briscoe^  is  inclined  to  attribute  post-operative 
collaps-e  to  the  half  of  the  diaphragm  concerned  and  its  asso- 
ciated muscles  being  put  out  of  action  owing  to  "  inflammation 
of  the  muscle  or  of  the  pleural  membrane  covering  it,"  and 
also  regards  the  recumbent  posture  as  an  agent  in  the  produc- 
tion of  the  collapse.  It  must  be  observed,  however,  that  in 
many  cases  the  injury  is  quite  distant  from  the  aifected  lung, 
and  that  pleurisy  is  not  in  other  cases  operative  in  producing 
the  phenomena. 

Before  concluding  this  chapter  we  may  allude  to  another 
cause,  which  has  been  held  to  account  for  more  or  less 
extensive  collapse  of  the  lung — namely,  the  excitation  of  the 
so-called  lung  reflex.  Dr.  Abrams  describes  "  dull  areas  "  due 
to  the  contraction  of  the  lung  as  being  produced  by  sharp 
percussion  of  the  chest  surface,  preferably  over  regions  in 
proximity  to  sternum  and  spine.  Areas  of  dulness  thus 
produced  are  circumscribed,  last  but  a  few  minutes,  and  are 
immediately  replaced  by  resonance  if  similar  percussion  be 
appHed  over  the  epigastrium.  This  phenomenon  he  desig- 
nated the  "lung  reflex  of  contraction."  Previously  he  had 
described  a  dilatation  of  the  lung  which  he  believed  to  follow 


350  DISEASES   OF   THE  LUNGS   AND   PLEUR.E 

"the  application  of  any  cutaneous  irritant,  whether  mechanic, 
chemic,  or  electric,"  to  the  chest-wall.* 

He  conceives  that  the  phenomena  are  due  to  reflex  contrac- 
tions or  relaxations  of  the  circular  and  longitudinal  fibres  of 
the  musculature  of  the  bronchi.  That  such  contractions  and 
relaxations  of  the  bronchial  muscles  are  operative  in  the 
normal  respiratory  function  and  in  some  of  its  disturbances  in 
disease  is  most  probable,  and  to  this  we  have  referred  in  earlier 
chapters  (see  pp.  8,  243),  but  we  venture  the  opinion  that  these 
observations  on  the  lung  reflexes  require  more  convincing 
repetition  and  demonstration.  They  have,  however,  attracted 
attention,  and  Sir  James  Barr*  regards  them  as  largely 
responsible  for  contralateral  collapse,  and  speaks  of  the 
excitation  of  the  lung  reflexes  by  vigorous  friction  over  the 
chest  as  clearing  up  conditions  of  extensive  pulmonary 
collapse. 

The  Diagnosis  of  massive  collapse  depends,  as  will  have  been 
sufficiently  indicated,  upon  the  rapid  development  of  physical 
signs  of  consolidation  of  the  lung,  enfeebled  breath-sounds, 
contraction  or  immobility  or  depression  of  the  affected  side 
with,  in  unilateral  cases,  displacement  of  heart  towards  that 
side,  and  laboured  and  exaggerated  breathing  on  the  sound 
side.  These  signs  may,  however,  be  obscured  by  such  compli- 
cations as  pleuritic  effusion. 

The  Prognosis  is  mainly  dependent  upon  the  caiuse.  In 
cases  of  central  nervous  origin,  such  as  those  following  upon 
diphtheritic  paralysis  or  ascending  paralysis,  the  prognosis 
is  grave,  although  by  no  means  necessarily  fatal.  In  traumatic 
cases  secondary  to  surgical,  gunshot  or  other  injuries,  the 
prognosis,  so  far  as  the  condition  of  lung  alone  is  concerned, 
is  favourable,  danger  arising  from  associated  lesions  or  com- 
plications. 

Treatment  consists  in  sustaining  the  patient,  careful  nursing, 
and  the  employment  of  remedies  appropriate  to  the  conditions 
with  which  the  collapse  is  associated.  Aeration  will  be  usefully 
aided  and  heart  power  supported  by  the  use  of  continuous  or 
intermittent  oxygen  inhalations.  Strychnia  is  perhaps  the 
other  remedy  of  greatest  value. 


COLLAPSE   OF   THE  LUNG  35 1 

REFERENCES. 

*•  {a)  "  The  Bradshaw  Lecture  on  Massive  Collapse  of  the  Lung,"  by 
William  Pasteur,  M.D.  (Lond.),  F.R.C.P.,  Tke  Lancet,  November  7, 
1908,  p.  1351. 
See  Also  [b)  "  Active  Lobar  CoUapse  of  the  Lung  after  Abdominal 
Operations,"  by  the  same  author,  The  Lancet,  October  8,  1910, 
p.  ic8o. 

^  "  Massive  Collapse  of  the  Lung  as  a  Result  of  Gunshot  Wounds,  with 
Especial  Reference  to  Wounds  of  the  Chest,"  by  John  Rose  Bradford, 
K.C.B.,  M.D.,  F.R.S.,  Quarterly  Journal  of  Medicine,  vol.  xii.,  Nos.  45 
and  46,  October,  1918;  January,  1919. 

^  Discussion  of  Gunshot  Wounds  of  the  Chest,"  by  Colonel  T.  R.  Elliott, 
Proceedings  of  the  Annual  Meeting  of  the  British  Medical  Association, 
Section  of  Surgery,  British  Medical  Journal,  April  12,  1919,  p.  442. 

*  "  The  Mechanism  of  Post-operative  Massive  Collapse  of  the  Lungs," 
by  J.  Charlton  Briscoe,  M.D.,  F.R.C.P.,  Quarterly  Journal  of  Medicine, 
vol.  xiii.,  No.  51,  April,   1920,  p.  293. 

^  "  The  Blues  (Splanchnic  Neurasthenia),  Causes  and  Cure,"  by  Albert 
Abrams,  M.D.,  Heidelberg,  New  York,  1908,  pp.  244,  247. 

°  "  The  Physics  of  the  Chest  and  their  Relation  to  Disease  and  Injuries 
of  the  Thoracic  Organs,"  by  Sir  James  Barr,  M.D.,  F.R.C.P.,  British 
Medical  Journal,  April  19,  1919,  p.  471. 


CHAPTER  XXI 

CEDEMA  OF  THE  LUNGS 

CEdema  of  the  lungs  consists  of  an  escape  of  serum  from  the 
vessels  into  the  texture  of  the  organ  and  into  its  alveolar  and 
bronchial  spaces.  As  a  chronic  condition  it  is  of  common 
occurrence,  and  is  familiar  to  every  practitioner;  but  it  may 
also  occur,  though  much  more  rarely,  suddenly,  and  in  an  acute 
form,  very  alarming  in  its  intensity,  and  often  speedily  fatal. 

The  two  forms  must  be  discussed  separately. 

I.  Chronic  Pulmonary  (Edema.— Of  this  variety  there  are 
many  causes,  but  they  range  themselves  naturally  under  two 
heads  :  (i)  disturbance  of  circulation;  (2)  morbid  conditions  of 
the  blood. 

Thus,  we  may  have  mechanical  oedema  from  retarded 
circulation,  which  may  be  due  to  mere  feebleness  of  heart,  or 
obstruction  to  the  passage  of  blood  through  the  lungs,  as  in 
emphysema,  mitral  stenosis,  mitral  regurgitation,  or  pressure 
on  the  pulmonary  veins  from  tumours.  Again,  the  powerful 
inspiratory  efforts  to  draw  air  into  the  lungs  through  the 
constricted  passages  in  croup,  asthma,  and  other  extended 
bronchial  obstructions,  cause  an  afflux  of  blood,  resulting  in 
some  cases  in-more  or  less  oedema  of  the  lung  textures. 

In  pneumonia  and  other  acute  inflammations  oedema  is  a 
consequence  of  the  active  hyperaemia  attendant  upon  the  early 
stage  of  inflammation.  Later,  as  we  have  elsewhere  pointed 
out,  the  oedema  in  this  complaint  is  not  infrequently  the  direct 
result  of  cardiac  failure,  and  is  thus,  in  great  part  at  least, 
mechanical  in  nature.  It  not  infrequently  also  persists  for 
some  considerable  time  after  the  acute  inflammation  of  the 
lung  has  passed  away,  owing  to  impairment  of  vessel  tonicity. 
Pulmonary  oedema  may  also  be  produced  by  all  those  morbid 
conditions  of  the  blood  which  impair  the  nutrition  of  the 
vessel  walls  and  favour  the  escape  of  serum  through  them. 

352 


CEDEMA  OF  THE  LUNGS  353 

Of  these  conditions  albuminuria  is  the  most  important,  but 
scurvy,  purpura,  and  anaemia  may  also  be  mentioned. 

Morbid  Anatomy. — CEdematous  lungs  are  large,  heavy,  wet, 
indented  by  the  ribs,  pitting  on  pressure,  and  on  section 
exuding  from  their  texture  and  tubes  an  abundant,  frothy 
serum,  sometimes  blood-stained.  These  characters  are 
especially  marked  at  the  bases  or  most  dependent  parts,  and, 
indeed,  may  only  be  apparent  there  unless  locally  determined 
in  other  situations.  CEdema  affects  both  lungs,  but  most 
commonly  one  side  is  more  affected  than  the  other,  owing  to 
the  posture  adopted  by  the  patient.  It  is  very  usual  also  to 
find  that  one  or  both  pleurae  contain  an  undue  amount  of 
serum.  Except  at  the  extreme  bases,  and  when  very 
thoroughly  waterlogged  by  old-standing  oedema,  the  lungs 
are  more  or  less  crepitant,  and  portions  removed  will  float  in 
water. 

Under  the  microscope,  the  alveoli  are  found  filled  with 
serous  fluid,  which  presents  after  hardening  a  finely  granular 
appearance,  and  stains  faintly  with  eosin.  Some  epithelial 
shedding  may  also  be  observed  in  the  alveoli ;  otherwise  the 
texture  of  the  organs  is  unchanged. 

Symptomatology. — The  symptoms  of  chronic  oedema  of  the 
lungs  are  mingled  with  those  of  the  other  diseases  of  which 
the  condition  is  but  a  consequence.  Dyspnoea,  straining  cough, 
with  copious  thin  watery  mucoid  sputa — sometimes,  in  cases  of 
acute  congestion,  tinged  or  streaked  with  blood — are  the  chief 
symptoms.  The  patient  sits  up  supported  in  bed,  the 
respiratory  movements  are  thoracic,  "  lifting"  in  character,  the 
bases  of  the  chest  receding  with  inspiration.  The  front  of  the 
chest  is  hyper-resonant,  the  posterior  bases  more  or  less  dull. 
Over  the  posterior  aspect  of  the  lungs,  extending  from  the 
base  upwards,  the  respiratory  sounds  are  enfeebled  or  annulled, 
and  fine  bubbling  rales  are  heard,  chiefly  with  inspiration. 
These  sounds  closely  simulate  pneumonic  crepitation,  emphy- 
sema crackle,  and  the  crepitation  of  air  penetrating  a  collapsed 
lung;  the  distinction  must  be  drawn  by  attention  to  associated 
percussion  and  auscultatory  phenomena. 

Prognosis. — Chronic  pulmonary  oedema  is  usually  of  grave 
significance.  In  chronic  Bright's  disease  and  in  cardiac  dropsy 
it  is  one  of  the  later  phenomena.  In  those  forms  of  heart 
disease,    however,   which   tell   directly   upon   the    circulation 

23 


354  DISEASES   OF  THE  LUNGS   AND  PLEURA 

through  the  king  a  certain  degree  of  pulmonary  oedema  may 
precede  general  dropsy,  and  may  long  persist  without  further 
consequences.  It  is  very  common  to  find  a  certain  amount  of 
pulmonary  oedema  as  a  permanent  condition  in  old  people  with 
feeble  hearts  and  emphysematous  lungs,  and  we  have  met  with 
several  persons  in  whom  slight  oedema  sounds  have  for  years 
persisted  on  one  side,  probably  as  the  result  of  a  past  inflam- 
matory attack.  No  doubt  some  of  these  cases  are  explained 
by  an  oedematous  condition  of  the  connective  tissue  uniting 
the  pleural  surfaces  over  a  lung  that  has  been  the  seat  of 
former  inflammation.  The  supervention  of  oedema  of  the 
lungs  in  acute  bronchitis  or  pneumonia  is  of  grave  augury, 
pointing  as  it  does  to  cardiac  failure. 

Treatment. — The  treatment  of  oedema  from  failing  heart  is 
referred  to  in  the  chapter  on  pneumonia.  In  cases  of  local 
oedema  from  loss  of  tone  of  vessels  after  inflammation,  iron, 
mineral  acids,  and  sometimes  small  doses  of  digitalis,  are  of 
great  value. 

In  other  cases  derivative  treatment  is  called  for.  The 
vegetable  diuretics,  juniper,  scoparium,  caffeine,  and  theobro- 
mine sodio-salicylate  (diuretin),  with  digitalis,  and  moderate 
doses  of  the  iodide  and  neutral  salts  of  potash,  are  then  valu- 
able; and  watery  purgatives  and  diaphoretics  should  be  used 
in  turn.  The  exact  nature  of  the  case,  whether  renal  or  car- 
diac, will  indicate  the  proper  selection  of  remedies;  in  cardiac 
cases  we  rely  more  upon  diuretics  and  digitalis,  with  occa- 
sional small  doses  of  mercurial  and  saline  aperients;  in  renal 
cases  our  derivative  treatment  is  rather  effected  through  the 
bowels  and  skin  by  brisk  watery  aperients  and  sudoriflcs, 
including  air  baths.  Dry-cupping  sometimes  gives  much  relief, 
especially  in  obstructive  cardiac  disease,  and  in  emphysema 
with  dilated  heart.  In  all  cases  a  tonic  supporting  line  of 
action  is  necessary. 

2.  Acute  Pulmonary  (Edema. — This  condition,  which  has 
been  recognised  for  many  years  in  France,  but  to  which  until 
recently  but  little  attention  has  been  paid  in  this  country, 
differs  much  from  the  chronic  form  which  we  have  hitherto 
been  discussing.  In  civil  life  it  is  perhaps  best  known  as  a  rare 
sequel  to  paracentesis  of  the  chest,  when  it  gives  rise  to  the 
so-called  "albuminous  expectoration  "^;  but,  as  we  shall  see,  it 
occurs  sometimes  quite  apart  from  pleurisy  or  paracentesis. 


(EDEMA  OF  THE  LUNGS  355 

The  sufferer  from  this  malady,  who  may  have  been 
apparently  in  his  usual  health,  is  suddenly  seized  with  extreme 
difficulty  in  breathing,  and  an  agonising  sense  of  impending 
dissolution;  cyanosis  follows,  and  very  soon,  in  characteristic 
cases,  a  frothy  exudate  is  coughed  up,  the  amount  being  often 
so  large  and  so  intimately  mixed  with  air  that  the  foam  wells 
from  nose  and  mouth.  On  auscultation,  abundant  crepitations 
are  heard  throughout  the  chest.  The  duration  of  the  attack 
varies.  The  patient  may  die  suffocated  within  a  few  minutes, 
but  more  often  the  symptoms  last  from  one  to  six  hours,  and 
then  gradually  subside.  In  not  a  few  instances  the  attacks 
show  a  disposition  to  recur.^  In  other  cases,  after  endeavour- 
ing for  some  time  to  clear  his  tubes,  by  constant  efforts  of 
cough  the  patient's  strength  fails,  he  becomes  unconscious, 
and  dies.  After  death,  the  lungs  are  commonly  found  in  a 
condition  of  great  oedema,  exuding  much  serous  fluid  on 
section. 

The  expectoration  is  characteristic.  It  is  large  in  amount, 
and  when  collected  often  measures  one  or  two  pints,  and  as 
much  as  two  litres  has  even  been  recorded.  After  being 
allowed  to  settle,  it  separates  into  two  layers,  an  upper  frothy 
layer,  and  a  lower  layer,  somewhat  viscid,  translucent,  and 
yellowish  or  yellowish-green  in  colour,  resembling  in  appear- 
ance the  fluid  removed  from  the  pleura  by  paracentesis.  It 
contains  large  quantities  of  albumin  and  globulin,  and  some- 
times becomes  solid  on  boiling,*  thus  contrasting  with  the 
non-albuminous  sputa  of  pituitary  catarrh  (see  p.  194). 

If  the  patient  recovers  from  the  first  attack — and  generally 
he  does  so — he  is  very  liable  to  suffer  from  further  attacks,  any 
one  of  which  may  prove  fatal. 

The  malady  is  happily  a  rare  one,  though  probably  not  so 
uncommon  as  is  usually  supposed.  As  Dr.  Riesman^  insists  in 
his  interesting  paper,  it  occurs  more  often  in  those  who  are 
the  subject  of  arterio-sclerosis,  heart  disease,  or  renal  disease, 
and,  as  Dr.  Leonard  Williams*  and  others  have  pointed  out, 
it  is  not  infrequently  associated  with  high  blood-pressure, 
especially  in  persons  of  middle  life  or  advancing  years.  We 
have  seen  several  such  cases  associated  with  a  blood-pressure 

*  For  further  details  we  may  refer  to  a  paper  by  one  of  us  relating  to 
this  subject,  in  which  a  chemical  analysis  of  the  expectoration  by 
Dr.  Hurtley  will  be  found  recorded.^ 


356  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

of  190-225.  It  has  been  observed  also  in  the  course  of  typhoid, 
rheumatic  and  scarlet  fever,  and  during  influenza  and  pneu- 
monia. As  we  have  already  said,  it  is  one  of  the  well-known, 
though  rare,  complications  of  paracentesis  of  the  chest,  the 
damaged  vessels  permitting  increased  transudation  when 
the  pressure  of  the  effused  fluid  has  been  removed  (see  p.  114). 
In  cases  of  extreme  effusion  the  condition  may  sometimes  be 
observed  to  be  commencing-  in  the  other  lung. 

The  cause  of  the  attacks,  which  are  apt  to  occur  at  night, 
and  not  infrequently  during  sleep,  is  not  very  clear.  The  most 
plausible  explanation  would  appear  to  be  that  offered  by 
Professor  Welch,^  of  Johns  Hopkins  University,  according  to 
which  the  condition  is  due  to  a  comparative  enfeeblement  of 
the  left  ventricle  of  the  heart,  so  that  it  discharges,  with  each 
systole,  rather  less  blood  than  it  receives  from  the  right  side 
through  the  pulmonary  veins.  The  pulmonary  system  thus 
becomes  overdistended,  and  acutely  oedematous  from  transuda- 
tion. Such  a  condition,  we  miay  add,  is  a  not  uncommon 
contributory  factor  to  the  fatal  result  in  angina  pectoris. 

Treatment. — When  first  called  to  a  case  of  this  kind  an  injec- 
tion of  morphia  gr.  |,  strychnine  gr.  /o>  ^^^  atropine  gr.  j^ 
should  be  given.  The  mental  distress  is  quieted  by  the 
morphia,  the  heart  is  stimulated  by  the  strychnine,  and  the 
pulmonary  exudation  perhaps  to  some  extent  checked  by  the 
atropine.  In  some  cases,  especially  those  in  which  the  blood- 
pressure  is  high,  venesection  to  ten  or  twelve  ounces  is 
indicated.  On  the  cardiac  theory  this  should  give  rehef  to  the 
exhausted  heart,  and  in  practice  it  has  been  found  to  do  good. 
It  may  in  some  cases  be  supplemented  by  leeches  or  dry- 
cupping  of  the  chest.  If  the  heart  is  beginning  to  fail, 
diffusible  stimulants  or  strychnine  subcutaneously  must  be 
freely  administered.  Inhalations  of  oxygen  will  also  be  found 
useful,  but  the  oxygen  must  be  given  continuously  during  the 
serious  symptoms.  In  cases  with  recurrent  attacks  a  course  of 
diuretics  may  be  prescribed,  on  the  assumption  that  some 
toxic  factor  may  be  at  work,  and  with  a  view  to  assist  elimina- 
tion by  the  kidneys. 

Irritant  Gas  Poisoning. 

Although  acute  oedema  of  the  lung,  as  we  have  seen,  is 
uncommon  in  civil  practice,  it  is  otherwise  in  war  since  the 


OEDEMA  OF  THE  LUNGS  35/ 

introduction  of  poison  gas  in  April,  1915.  Both  chlorine  and 
phosgene  (COCI2)  are  pulmonary  irritants,  and  when  inhaled 
they  produce  an  acute  pulmonary  oedema  of  inflammatory 
nature,  which  is  often  fatal.® 

On  first  exposure  to  the  gas  the  soldier  at  once  experiences 
a  catching  of  the  breath  and  choking,  and  a  feeling  of  inability 
to  breathe  freely.  Vomiting  and  cough  soon  follow,  and  after 
an  interval,  which  may  vary  from  a  few  minutes  to  some  hours, 
corresponding  to  the  concentration  of  the  gas  and  the  dura- 
tion of  the  exposure,  inflammatory  reaction  occurs  in  the  lung- 
tissue,  leading  to  acute  oedema  and  the  appearance  of  the 
characteristic  albuminous  expectoration.  Cyanosis  soon 
manifests  itself,  or  with  phosgene  more  often  a  pallid  type  of 
asphyxia,  symptomatic  of  cardiac  failure.  If  the  patient 
survives  for  forty-eight  hours,  he  will  usually  recover, 
though  convalescence  may  be  tardy,  and  some  degree  of 
bronchial  catarrh  is  apt  to  persist. 

Treatment  must  be  on  lines  similar  to  that  advised  in  cases 
occurring  in  civil  practice,  morphia,  however,  being  withheld, 
unless  urgently  demanded  by  the  patient's  anxiety  and  distress. 
In  view  o£  the  conditions  of  active  service,  it  must  be  especially 
remembered  that  rest  and  zvarmth  are  fundamental  factors  in 
the  treatment,  each  helping  to  diminish  metabolic  activity,  and 
thus  to  lessen  the  need  for  oxygen  from  which  the  patient  is 
suffering.  Venesection,  if  the  case  be  a  cyanotic  one  and  the 
right  heart  dilated,  and  oxygen  inhalations,  with  strychnine 
and  diffusible  stimulants  when  required,  will  again  constitute 
our  main  lines  of  treatment. 


REFERENCES. 

'■  "  Albuminous  Expectoration  following  Paracentesis  of  the  Chest," 
by  P.  Horton-Smith  Hartley,  M.D.,  St.  Bartholomew''  s  Hos-pital  Re  forts, 

1906,  vol.  xli.,  p.  77. 

^  "  Paroxysmal  Pulmonary  CEdema  and  its  Treatment,"  by  Alfred 
Stengel,  M.D.,  The  Ainerican  Journal  of  the  Medical  Sciences,  New  Series, 
vol.  cxii.,  191 1,  p.  1. 

^  "  Acute  Pulmonary  CEdema,  with  Special  Reference  to  a  Recurrent 
Form,"  by  David  Riesman,  M.D.,  The  American  Journal  of  the  Medical 
Sciences,  1907,  New  Series,  vol.  cxxxiii.,  p.  88. 

"  "  Acute  Pulmonary  CEdema,"  by  Leonard  Williams,  M.D.,  The  Lancet, 

1907,  vol.  ii.,  p.  1606. 


358  DISEASES   OF  THE  LUNGS   AND  PLEURA 

^  (i)  "  Zur  Pathologic  des  Lungen  Odems,"  von  Dr.  W.  H.  Welch,  aus 
New  York;  Archiv  fur  Pathologische  Anatomie  und  Physiologic  und 
fiir  Klinische  Medicin.  Herausgegeben  von  Rudolf  Virchow. 
Berlin,  1878,  Band  Ixxii.,  p.  375.  See  also — 
(2)  "  Edema  :  a  Consideration  of  the  Physiologic  and  Pathologic 
Factors  concerned  in  its  Formation,"  by  S.  J.  Meltzer,  M.D., 
American  Medicine,  p.    195.     Philadelphia,  U.S.A.,  1904. 

^  For  a  study  of  gas-poisoning  reference  should  be  made  to 

{a)  The  Reports  of  the  Chemical  Warfare  Medical  Committee,  published 
by  the  Medical  Research  Committee,  Nos.  1-8,  1918,  and  the  Atlas 
of  Gas-Poisoning  (191 8)  which  accompanies  them.  See  also 
{b)  "  Gas-Poisoning  :  Pathological  Symptoms  and  Clinical  Treat- 
ment," by  Leonard  HiU,  M.D.,  F.R.S.,  Transactions  of  the  Medical 
Society  of  London,  vol.  xxxix.,  1916,  p.  114. 


CHAPTER  XXII 

ABSCESS  AND  GANGRENE  OF  THE  LUNG 

Abscess  of  the  Lung. 

Circumscribed  suppuration  of  the  pulmonary  tissues  may 
arise  from  a  variety  of  causes,  the  most  important  of  which 
are  acute  inflammation,  whether  lobar  or  broncho-pneumonic, 
especially  in  the  subjects  of  diabetes  or  chronic  alcoholism; 
wounds  of  the  thorax;  lodgment  of  foreign  bodies;  circum- 
scribed gangrene;  pyasmic  infarctions  and  other  infective 
emboli.  It  may  also  arise  from  extension  of  suppuration  from 
adjacent  parts,  e.g.,  suppurating  bronchial  glands,  mediastinal 
abscesses,  empyema;  or  it  may  result  from  a  malignant 
growth  of  the  oesophagus  ulcerating  into  the  lung. 

In  acute  lobar  pneumonia  abscess  formation  is  rarely  met 
with  except  in  broken  and  debilitated  constitutions,  and  a 
history  of  long  indulgence  in  alcohol  is  usually  to  be  obtained. 
The  abscesses  are  generally  of  small  size,  numerous  and 
irregular  in  shape,  though  sometimes  a  single  larger  abscess 
may  be  found. 

Broncho-pneumonia  is  more  frequently  followed  by  suppura- 
tion than  is  true  lobar  pneumonia.  The  broncho-pneumonia 
is  generally  septic  in  nature,  produced  by  the  passage  over 
the  insensitive  glottis  of  acrid  discharges  from  suppurating 
wounds  or  cancerous  sores  in  the  mouth,  or  of  decomposing 
particles  of  food  when  the  patient  is  in  a  state  of  coma.  The 
areas  of  suppuration  are  usually  multiple  and  small. 

Multiple  abscesses  are,  however,  most  commonly  produced 
by  infective  emboli,  especially  in  pyaemia.  These  set  up  areas 
of  acute  septic  lobular  pneumonia,  which  rapidly  undergo 
suppuration,  giving  rise  to  small  abscesses,  which  are  often 
thickly  disseminated  throughout  both  lungs. 

Symptoms. — The  formation  of  pus  in  the  lungs,  as  in  other 
organs,  is  usually  attended  with  severe  rigors  and  pyrexia 

359 


360  DISEASES   OF  THE  LUNGS   AND  PLEURA 

and  with  symptoms  of  great  prostration.  The  appearance  of 
the  patient,  the  high  temperature,  and  rapid  breathing,  suggest 
that  the  lung  is  the  seat  of  inflammation,  but  the  first  evident 
symptom  of  an  abscess  may  be  the  sudden  expectoration  of 
pus  with  fragments  of  lung  tissue. 

Physical  Signs. — If  the  abscess  be  of  any  size,  and  com- 
municate with  a  bronchus,  the  signs  observed  will  be  dulness 
on  percussion,  with  gurgling  rales  and  the  other  indications 
of  cavity.  In  more  minute  and  scattered  abscesses  the  signs 
are  often  indefinite  and  slight,  or  may  be  those  of  softening 
of  the  lung.  To  X-ray  examination  the  abscess  will  produce 
a  shadow,  more  characteristic  if,  as  is  sometimes  the  case  in 
larger  cavities,  much  air  be  contained  as  well  as  pus. 

Treatment. — The  treatment  of  pulmonary  abscess  consists 
generally  in  the  pursuance  of  the  remedies  for  the  diseases 
that  may  have  led  up  to  it,  and  particularly  is  this  the  case  with 
those  grave  forms  of  disseminated  abscesses  associated  with 
pyaemia.  Quinine  or  bark  and  mineral  acids  are  useful.  Dis- 
infectant inhalations  are  also  of  service,  and  in  circumscribed 
cases  especially  the  patient  should  be  encouraged  to  evacuate 
the  contents  of  the  abscess  cavity  from  time  to  time.  Under 
such  ordinary  measures  of  treatment,  with  good  ventilation 
and  change  of  air  at  the  earliest  moment,  abscess  of  the  lung 
sometimes  heals,  perhaps  more  frequently  than  is  generally 
supposed. 

Surgical  Intervention. — In  other  cases  the  question  of  opera- 
tive treatment  by  opening  and  draining  the  abscess  must  be 
considered.  This  may  be  recommended  if  definite  signs  of 
localised  abscess  cavity  are  present,  and  if  after  a  period  of 
observation  there  be  no  amelioration  in  the  patient's  symp- 
toms, as  indicated  by  a  fall  of  temperature  and  a  lessening 
of  the  expectoration.  Much  depends  upon  the  seat  of  the 
abscess,  basic  cases,  owing  to  the  difficulty  of  natural  drainage, 
more  often  requiring  interference. 

The  records  dealing  with  cases  of  this  kind  treated  surgically 
by  incision  and  drainage  are  most  encouraging.  Two  success- 
ful cases  were  published  in  1889  by  Dr.  S.  Smith^  and  by  Mr. 
J.  D.  Harris,"  and  these  are  among  the  earliest  cases  recorded 
in  England.  The  recent  figures  of  Garre  and  Quincke^  show 
that  out  of  182  cases  treated  by  operation,  148  were  cured  and 
34  died,  a  mortality  of  175  per  cent. 


ABSCESS    AND   GANGRENE   OF   THE   LUNG  361 

(i)  To  Define  the  Outline  of  the  Cavity. — The  position  and 
outline  of  the  cavity  are  first  defined  as  accurately  as  possible, 
both  clinical  and  X-ray  methods  of  examination  being  em- 
ployed. For  this  purpose  a  circle  should  be  drawn  upon  the 
chest  to  include  the  centre  of  greatest  intensity  of  physical 
signs.  Then,  using  a  stethoscope  with  a  small  chest-piece, 
this  centre  should  be  gradually  approached  from  all  sides,  and 
a  mark  made  at  each  point  where  pectoriloquy  and  cavernous 
breath-sound  are  first  distinctly  recognisable.  In  this  way  an 
outer  circle  is  drawn,  marking  off  a  larger  area.  Further,  the 
limits  of  dulness  should  be  defined,  and  the  position  of  other 
organs,  the  heart  and  diaphragm  especially,  taken  into  careful 
account. 

(2)  Exploration. — The  physician  having  thus  marked  out  the 
area  for  exploration,  and  having  controlled  his  results  as  far 
as  possible  by  X-ray  examination,  a  puncture  should  be  made 
with  an  exploring  needle-syringe,  with  not  too  fine  a  needle, 
through  the  central  part  of  the  inner  circle,  pushing  the  needle 
boldly  in  and  quite  vertically  to  the  surface  at  the  spot  chosen. 
Several  points  may  be  thus  explored  should  the  first  puncture 
not  be  successful. 

The  sign  of  success  is  the  withdrawal  of  purulent  material, 
showing  that  the  cavity  has  been  struck;  and  the  character  of 
the  fluid,  whether  foetid  or  otherwise,  can  now  be  ascertained. 
The  instrument  should  be  introduced,  an  inch  and  a  half  or 
two  inches  in  the  first  place,  and  the  syringe  exhausted;  if 
no  matter  appears,  the  needle  should  be  pushed  in  farther,  and 
then  slowly  and  cautiously  withdrawn,  the  operator  testing 
each  depth  from  the  surface,  and  also  endeavouring  to  ascer- 
tain by  lateral  movements  the  resistance  of  tissues  and  degree 
of  fixity  of  the  instrument.  The  length  of  the  exploring 
needle  should  be  known  beforehand,  so  that  its  depth  of 
penetration  may  at  any  time  be  calculated.  In  the  event  of 
failure  to  strike  the  cavity,  it  is  probably  best  to  desist  from 
further  measures,  but  a  fearless  and  thorough  exploration 
should  be  made  at  several  points. 

Further  Steps  in  the  Operation. — If  the  withdrawal  of  even 
a  few  drops  of  discoloured  fluid  or  pus  show  that  the 
cavity  has  been  reached,  the  needle  may  be  retained  in  situ 
as  a  guide  or  withdrawn  at  the  discretion  of  the  surgeon. 
A  portion  of  two  ribs,  one  above  and  one  below  the  site  of 


362  DISEASES   OF  THE  LUNGS   AND  PLEURA 

puncture,  should  next  be  excised,  care  'being  taken  not  to 
wound  the  pleura.  Since  it  is  impossible  to  say  whether  the 
pleura  is  adherent  or  not,  a  circle  of  stitches  two  inches  in 
diameter,  as  recommended  by  Sir  Rickman  J.  Godlee,*  to  whose 
writings  we  must  refer  the  reader  for  further  surgical  details, 
should  be  inserted  around  the  site  of  puncture,  uniting  the 
pleural  layers  and  penetrating  the  lung  to  the  depth  of  half 
an  inch.  In  this  way  the  cavity  of  the  pleura  is  completely 
shut  off.  The  pleural  layers  are  then  divided,  and  if  the  needle 
has  been  withdrawn,  the  position  of  the  pus  is  again  locahsed 
by  the  exploring  syringe.  Sinus  forceps  are  now  passed  along 
the  directing  needle  until  the  pus  is  reached,  then  opened  out 
and  withdrawn,  so  as  to  rend  open  the  cavity  with  the  least 
risk  of  serious  haemorrhage.  The  finger  can  now  be  inserted, 
the  cavity  thoroughly  explored,  its  dimensions  in  different 
directions  ascertained,  and  a  sufficiently  large  drainage-tube 
introduced. 

Smart  haemorrhage  will  sometimes  occur  during  this  opera- 
tion, as  might  be  expected,  but  on  air  being  freely  admitted 
it  usually  soon  ceases;  if  not,  the  wound  must  for  a  short 
time  be  plugged.  We  have  not  yet  seen  more  than  enough 
bleeding  to  cause  momentary  anxiety.  Still,  it  is  most  desir- 
able to  avoid  as  much  as  possible  the  use  of  cutting  instru- 
ments in  dealing  with  the  lung. 

In  some  cases,  although  the  exploring  syringe  gives 
evidence  of  having  reached  the  cavity,  it  cannot  be  located 
at  the  operation,  the  needle  having  perhaps  become  displaced. 
Under  these  circumstances  it  is  best  to  leave  in  a  drainage- 
tube  in  the  hope  that  the  cavity  may  finally  discharge  through 
it.  This  happened  in  a  successful  case  of  Dr.  Cayley's,  which 
was  operated  upon  by  Mr.  (now  Sir  Alfred)  Pearce  Gould.^ 

The  treatment  subsequent  to  the  operation  must  be  carried 
on  in  accordance  with  ordinary  principles,  and  the  special 
circumstances  of  each  case. 

Gangrene  of  the  Lung. 

Death  of  a  portion  of  the  substance  of  the  lung  may  occur 
under  two  forms — (a)  circumscribed;  (b)  diffuse. 

(a)  The  circumscribed  form  is  that  usually  seen,  the  gan- 
grenous area  being  distinctly  defined,  and  varying  in  size 
from  that  of  a  nut  to  a  considerable  patch  involving  the 


ABSCESS   AND   GANGRENE  OF  THE  LUNG  363 

greater  part  of  one  lobe.  The  lower  lobes  and  superficial 
parts  of  the  lungs  are  most  frequently  affected.  The  necrosed 
portions  of  the  pulmonary  tissue  become  moist,  soft,  pulpy,  of 
a  bluish-green  or  blackish  colour,  and  evolve  a  peculiar  and 
highly  offensive  odour.  These  portions  consist  of  altered 
lung  elements  and  blood-corpuscles,  together  with  amorphous 
debris.  The  limits  of  the  dead  tissue  are  indicated  by  a  zone 
of  hyperaemia  and  consolidation.  The  necrotised  lung  may 
slough  and  be  discharged  through  a  bronchus,  leaving  a 
ragged  cavity  behind.  Frequently,  however,  the  pleura  is  in- 
volved, and  the  foetid  material  may  find  its  way  into  the 
pleural  cavity,  unless,  as  sometimes  happens,  adhesions  have 
previously  formed  between  the  pulmonary  and  parietal  layers. 

(b)  In  the  diffuse  form  there  is  no  line  of  demarcation 
between  the  dead  and  healthy  tissue,  but  inflamed,  congested, 
and  gangrenous  lung  are  all  mixed  up  together.  The  greater 
portion  of  one  lobe,  or  of  an  entire  lung,  may  be  involved, 
or  perhaps  both  lungs  may  be  affected  at  several  points. 

Etiology. — Necrosis  of  a  portion  of  the  lung  is  the  result 
of  obstruction  of  vessels  and  deprivation  of  blood-supply.  It 
may  be  secondary  to  inflammation  of  the  pulmonary  tissue, 
however  produced,  or  be  merely  mechanical  in  origin  as  from 
embolism  of  a  branch  of  the  pulmonary  artery.  Gangrene, 
with  its  characteristic  signs,  implies  the  presence  of  secondary 
putrefactive  changes  in  this  necrotic  area. 

Gangrene  may  sometimes  arise  as  a  complication  of  acute 
pneumonia,  especially  when  occurring  in  drunkards  or  those 
suffering  from  diabetes.  Pysemic  emboli,  or  the  inhalation  of 
foetid  discharges  from  a  cancrum  oris  or  malignant  growth 
in  the  mouth,  or  the  bursting  of  a  neighbouring  abscess  into 
a  bronchus,  may  also  give  rise  to  it.  In  the  insane  it  is  not 
infrequently  observed,  possibly  from  the  inhalation  of  food 
during  its  passage  over  an  imperfectly  sensitive  glottis;  and 
for  a  similar  reason  it  sometimes  occurs  after  tracheotomy. 
Retention  of  putrid  bronchial  secretion,  with  secondary  septic 
broncho-pneumonia,  may  also  produce  it,  as  seen  in  bron- 
chiectasis. Gangrene  may  also  be  caused  by  wounds  of  the 
chest,  and  the  lodgment  in  the  lung  of  foreign  bodies,  such  as 
bullets  and  pieces  of  cloth.  It  may  complicate  such  debilitat- 
ing diseases  as  smallpox,  typhus  fever,  and  the  like,  when  the 
condition  may  be  generally  traced  to  thrombosis  of  a  branch 


364  DISEASES   OF  THE  LUNGS   AND  PLEURA 

of  the  pulmonary  artery.  Pressure  of  mediastinal  growths 
and  aneurism,  which  interferes  with  the  circulation  through 
the  lungs,  is  another  cause.  Whatever  the  preceding  condi- 
tions, it  must  be  repeated  that  thrombosis  or  embolism  block- 
ing a  branch  or  branches  of  the  pulmonary  artery  is  the 
penultimate  occurrence. 

Bacteriological  examination  reveals  the  presence  in  the 
gangrenous  tissue  of  numerous  varieties  of  micro-organisms. 
Among  those  that  may  be  found  we  may  mention  the  pyo- 
genic cocci,  whether  staphylococci,  streptococci  or  pneumo- 
cocci,  the  bacillus  proteus  vulgaris,  bacillus  coli,  bacillus 
pyocyaneus,  and  many  others,  among  which  may  be  included 
various  anaerobic  organisms.  In  several  cases  it  is  interest- 
ing to  note  that  acid-fast  bacilli,  allied  to  the  tubercle  bacillus, 
have  been  discovered.*  These  organisms  no  doubt  all  play 
a  part  in  producing  the  inflammatory  condition  which  leads 
to  the  death  of  the  lung  tissue,  or  in  originating  the  secondary 
putrefactive  changes;  it  is  evident  that  no  one  organism  can 
be  held  responsible  for  the  condition. 

Symptoms. — The  most  characteristic  symptoms  of  gan- 
grene of  the  lung  are  the  peculiarly  offensive  odour  of  the 
breath  associated  with  the  copious  expectoration  of  foetid 
and  discoloured  sputum  containing  lung  tissue.  Foetid 
empyema,  post-pharyngeal  or  other  foetid  abscess,  might 
possibly  be  confounded  with  gangrene  of  the  lung;  but  the 
condition  most  likely  to  be  mistaken  for  it  is  old-standing 
bronchiectasis  suddenly  becoming  foetid  from  necrosis  of 
portions  of  mucous  membrane,  and  from  this  it  is  to  be  dis- 
tinguished by  the  previous  history  of  the  case  and  the 
presence  of  elastic  fibres  in  the  sputum.  Such  fibres  are  not, 
however,  invariably  found  in  gangrenous  sputum,  for  reasons 
which  we  have  already  explained  (see  p.  73). 

The  general  symptoms  are  extreme  depression,  asthenia, 
and  collapse,  and  the  termination  is  usually  fatal.  Haemoptysis 
from  the  opening  up  of  bloodvessels  is  not  uncommon,  and 
we  have  known  it  to  be  the  direct  cause  of  death.  Fever  is 
more  or  less  of  the  irregular  suppurative  type. 

Physical  Signs. — In  the  early  stages  the  auscultatory  signs 
are  indistinct  and  not  to  be  relied  upon;  but  later,  if  the 
gangrene  be  circumscribed  and  near  the  surface,  the  physical 
signs  are  dulness  over  the  affected  area,  with  gurgling  rales. 


ABSCESS   AND   GANGRENE  OF  THE  LUNG  365 

accompanied  by  an  amphoric  quality  of  breath-sound.  The 
distinctness  of  these  signs  varies,  however,  according  to  the 
position  of  the  cavity  and  its  degree  of  freedom  from  shreddy 
gangrenous  tissue.  X-rays,  as  with  pulmonary  abscess,  may 
sometimes  give  an  indication  of  the  cavity,  but  here  again 
much  depends  upon  the  presence  of  air  as  well  as  pus  within 
the  cavity  and  upon  the  condition  of  the  surrounding  lung, 
whether  much  consolidated  or  not. 

Treatment. — This  should  be  nourishing  and  stimulating, 
alcohol  being  freely  given.  Antiseptics  internally  are  of 
little  use ;  but  inhalations  of  creosote,  carbolic  acid  or  eu- 
calyptus, such  as  that  sug"gested  in  an  earlier  chapter  (p.  218), 
should  be  employed.  Under  such  treatment  in  a  certain  pro- 
portion of  cases  the  sphacelus  may  be  expelled  through  the 
bronchial  tubes,  the  cavity  contract  and  the  patient  make  a 
good  recovery.  But  such  instances  are  unfortunately  rare, 
and  in  cases  of  circumscribed  gangrene  with  symptoms  of 
hectic,  in  which  the  locality  of  the  gangrenous  cavity  can  be 
fairly  defined,  surgical  treatment  should  be  attempted. 

If  operation  be  performed  early,  and  the  cavity  be  opened 
and  drained  in  the  manner  already  described  (see  p.  361),  the 
outlook  is  greatly  improved.  Thus,  in  his  address  at  the 
French  Surgical  Congress  as  far  back  as  1895,  M.  Reclus^ 
pointed  out  that,  whereas  the  mortality  from  gangrene,  if  un- 
treated, was  probably  not  less  than  75  per  cent.,  the  figures 
after  operation  showed  a  death-rate  of  only  38-5  per  cent, 
among  83  cases  treated.  The  more  recent  figures  of  Garre 
and  Quincke^  are  still  more  favourable;  of  281  cases,  197  were 
cured,  with  84  deaths,  a  mortality  of  293  per  cent. 

It  is  to  be  observed,  however,  that  the  cases  which  would 
be  selected  for  operation  are  not  consecutive  cases  of  gan- 
grene of  all  sorts,  but  those,  such  as  we  have  spoken  of  above, 
in  which  the  cavity  is  fairly  restricted  and  defined.  Neverthe- 
less, the  figures  indicate  that  in  suitable  cases  surgical  inter- 
vention is  both  justifiable  and  proper. 

In  cases  of  diffused  gangrene  surg-ical  treatment  is  of  no 
avail. 

REFERENCES. 

1  "  Gangrenous  Abscess  of  the  Lung  treated  by  Incision  and  Drainage  : 
Recovery,"  by  Solomon  C.  Smith,  M.D.,  The  Lancet,  1889,  vol.  ii.,  p.  113. 


366  DISEASES   OF  THE  LUNGS   AND   PLEURA 

^  "  A  Case  illustrating  the  Value  of  Surgical  Treatment  of  Pulmonary 
Cavities,"  by  J.  Delpratt  Harris,  M.R.C.S.,  British  Medical  Journal, 
1889,  vol.  i.,  p.  994. 

^  The  Surgery  of  the  Lung,  by  C.  Garre  and  H.  Quincke,  2nd  edition, 
1912  (translated  by  David  M.  Barcroft,  M.D.).     London,  p.  133. 

*  Operations  upon  the  Thorax  and  its  Contents,  by  Rickman  J.  Godlee, 
M.S.,  F.R.C.S.,  A  System  of  Operative  Surgery,  by  various  Authors, 
edited  by  F.  F.   Burghard,  M.S.,  F.R.C.S.     London,   1914,  p.  723. 

*  "  A  Case  of  Gangrene  of  the  Lung  following  Necrosis  of  the  Temporal 
Bone,  the  Result  of  Scarlet  Fever ;  Treatment  by  Drainage  :  Recovery," 
by  W.  Cayley,  M.D.,  and  A.  Pearce  Gould,  M.S.,  Transactions  of  the 
Royal  Medical  and  Chirurgical  Society,  London,  1884,  vol.  Ixvii.,  p.  209. 

^  See  "  Acid-Proof  Bacilli  in  Five  Cases  of  Pulmonary  Gangrene"  (with 
bibliography),  by  W.  Ophuls,  M.D.,  The  Journal  of  Medical  Research, 
Boston,  U.S.A.,   1902,  vol.  viii.,  p.  242. 

'  "  Chirurgie  du  Poumon  (Plevre  exceptee)."  Rapport  par  le  Dr. 
Paul  Reclus,  Neuvieme  Congres  Frangais  de  Chirurgie,  Paris,  1895,  p.  50. 
A  translation  of  this  article,  though  without  the  tables,  will  be  found  in 
Mr.  Stephen  Paget's  work.  The  Surgery  of  the  Chest,  p.  443.  Bristol 
and  London,  1896. 


CHAPTER   XXIII 

-HYDATID  DISEASE  OF  THE  LUNGS 

Hydatid  disease,  though  rare  in  the  United  Kingdom,  is 
prevalent  in  AiistraHa,  New  Zealand,  Iceland,  the  Shetland 
Isles,  and  in  the  Argentine.  Next  to  the  liver,  which  is 
affected  in  more  than  half  the  cases  of  hydatid  disease,  the 
lung  is  most  frequently  the  seat  of  the  parasite.*  In  Australia 
the  lung-  is  attacked  in  about  i6  per  cent,  of  the  cases  re- 
ported.^" In  Europe  the  proportion  is  not  so  high,  Neisser's 
statistics  of  900  cases  placing  the  percentage  of  the  pulmonary 
variety  at  7'4,^''  and  in  Iceland  it  is  said  to  be  even  less.^"  In 
the  British  Isles  the  lung  is  rarely  affected,  and  chiefly 
amongst  those  who  have  resided  in  Australia  and  New 
Zealand. 

The  disease  is  most  prevalent  in  the  male  sex.  It  may 
occur  at  any  age,  although  it  is  rare  below  the  age  of  ten 
and  above  that  of  fifty.  It  is  more  frequent  in  the  right  than 
in  the  left  lung;  this  preponderance  in  favour  of  the  right 
side  being  most  marked  amongst  cases  of  basic  distribution. 
Sometimes  the  acephalocysts  are  multiple,  and  affect  both 
lungs.  The  bases  or  central  portions  of  the  lungs  are  most 
commonly  affected,  but  one  or  both  apices  may  be  attacked. 
The  cysts  may  be  found  entire  or  broken  in  the  bronchial 
tubes  on  their  way  to  expulsion;  they  have  also  been  found 
in  the  pulmonary  arteries  and  right  side  of  the  heart,  having 
been  conveyed  there  from  some  distant  point.  The  pleural 
cavity  is  rarely  the  primary  seat  of  hydatid. 

The  source  of  the  disease,  as  of  hydatids  in  other  organs, 
is  the  introduction  of  the  ovum  of  Tcenia  echinococcus  dis- 
charged from  the  alimentary  canal  of  the  dog.     In  England 

*  We  are  greatly  indebted  in  our  remarks  on  "  Hydatid  of  the  Lung  " 
to  the  writings  of  the  late  Dr.  Davies  Thomas,  of  Adelaide,  and  also  to  the 
lectures  of  Dr.  A.  A.  Lendon,  of  the  same  State. 

367 


368  DISEASES    OF   THE   LUNGS   AND   PLEURAE 

this  small  parasite,  the  total  length  of  which  is  only  one- 
quarter  of  an  inch,  is  extremely  rare.  In  Australia,  on  the 
contrary,  the  late  Dr.  Davies  Thomas  found  it  in  nearly  40  per 
cent,  of  the  stray  dogs  examined  by  him,^"  the  parasite  having 
been  acquired  by  their  feeding-  on  the  offal  of  sheep  or  cattle, 
the  most  common  intermediate  hosts,  infected  with  the  disease 
in  the  bladder-worm  stage.  The  ovum  usually  effects  its 
entrance  into  man  throug^h  drinking-water,  finding  its  way  to 
the  lungs  from  the  digestive  canal,  after  passing  en  route 
through  the  liver  and  the  right  heart.  The  above  facts  ex- 
plain the  great  prevalence  of  hydatid  disease  in  Australia,  and 
especially  in  the  country  districts  of  the  southern  portion  of 
the  Continent,  for  there  we  find  countless  herds  of  cattle  and 
flocks  of  sheep,  as  well  as  innumerable  dogs,  many  of  them 
already  infected;  while  the  water-supply,  consisting  often  of 
unprotected  surface  pools,  is  not  infrequently  open  to  direct 
contamination  by  the  dogs  themselves.  All  the  conditions 
necessary  for  the  spread  of  the  disease  are  thus  at  hand. 

The  morbid  anatomy  of  an  hydatid  tumour  of  the  lung  is 
after  the  same  pattern  as  that  of  similar  cysts  elsewhere,  the 
external  investment  being  furnished  by  the  more  or  less 
smoothed,  thickened,  and  condensed  pulmonary  tissue.  The 
investment  of  the  pulmonary  hydatid  is  thus  in  the  lung  very 
vascular,  and  with  it  one  or  more  bronchial  tubes  may  com- 
municate. In  the  lung  more  often  than  the  liver  the  cysts 
are  sterile  and  contain  no  daughter  cysts. 

Symptoms. — The  symptoms  and  signs  of  hydatid  of  the 
lung  may  be  conveniently  divided  into :  (i)  those  presented 
by  the  tumour  before  rupture;  (2)  those  which  occur  during 
and  after  rupture. 

I.  Before  Rupture. — Unbroken  cysts  which  have  not 
attained  considerable  size  may  give  rise  to  no  recognisable 
signs;  and  so  slow  and  insidious  is  their  growth  that  even 
large  tumours  may  exist  for  a  long  time  unsuspected.  Cough, 
haemoptysis,  pain,  and  dyspnoea,  are  the  chief  symptoms  that 
may  be  present  in  this  stage,  and  may  lead  to  a  mistaken 
diagnosis  of  phthisis. 

The  cough  is  dry,  teasing  in  character,  sometimes  attended 
with  slight  bronchial  expectoration;  occasionally  it  is  dis- 
tinctly paroxysmal,  and  has  a  laryngeal  croupy  character. 
Haemoptysis,  although  often  met  with  at  this  stage,  is  usually 


PLATE  XX 


X-Ray  Photograph  of  a  Case  of  Hydatid  Disease  of  the  Lung,  showing 
the  well-defined  rounded  shadow  so  suggestive  of  this  condition. 


To  face  p.  369. 


HYDATID   DISEASE  OF  THE  LUNGS  369 

but  slight  in  amount,  from  a  mere  streak  or  staining  of  the 
sputum  to  a  teaspoonful  or  so,  and  is  due  to  active  pulmonary 
congestion  set  up  by  the  growing-  parasite  in  its  immediate 
neighbourhood. 

Pain  is  not  felt  except  when  the  cyst  has  approached  near 
enough  to  the  surface  to  involve  the  pleura;  but  before  this 
period  an  ill-defined  uneasiness  may  be  experienced.  The 
dyspnoea  is  inappreciable  except  in  the  case  of  a  large  cyst,  or 
one  situated  near  the  root  of  the  lung.  The  centric  pressure 
symptoms  of  an  hydatid  are,  however,  never  very  marked. 

The  physical  signs  before  rupture  may,  in  cases  of  small  or 
deeply-seated  cysts,  be  completely  obscured.  Over  tumours  of 
larg'er  size,  and  nearer  the  surface,  a  certain  degree  of  fulness 
is  to  be  observed,  with  effacement  of  the  intercostal  spaces 
over  a  limited  area.  Percussion  dulness,  having  a  very  definite 
and  circular  outline,  is  obtained  over  this  region,  beyond 
which  there  is  normal  or  modified  pulmonary  resonance.  A 
certain  degree  of  elasticity  may  be  appreciated  on  percussion 
over  the  most  central  point,  amounting  possibly  to  "  hydatid 
thrill,"  a  rare  sign,  however,  in  hydatid  cysts  of  the  chest,  and 
in  no  way  pathognomonic,  since  we  have  known  it  well  marked 
at  the  superior  level  of  the  fluid  in  pyopneumothorax,  and 
perfectly  elicited  in  a  case  of  hydronephrosis.  Over  the  region 
of  dulness  vocal  fremitus  and  respiratory  murmurs  are 
enfeebled  or  absent;  and  in  some  cases  pleuritic  friction  is 
present  over  the  tumour.  Displacement  of  the  heart  and  other 
organs  may  occur. 

In  association  with  these  more  or  less  positive  signs  and 
symptoms  there  are  the  important  facts  of  the  absence  of 
pyrexia,  the  but  slight  interference  with  general  health  and 
nutrition,  and  the  very  insidious  and  ill-defined  onset  of  the 
disease.  The  position  of  the  physical  signs  is  sometimes  of 
value  in  diagnosis,  when  they  present  in  the  mammary  or 
axillary,  infrascapular,  or  some  other  unusual  situation  not 
commonly  affected  by  more  ordinary  lesions.  Of  great 
assistance  also  is  an  X-ray  examination  in  disclosing  the 
hydatid,  the  cyst  commonly  appearing*  as  a  circular  shadow 
clearly  defined  from  the  surrounding  lung,  and  presenting  a 
picture  which  is  almost  diagnostic  (see  Plate  XX.). 

A  blood  examination  often  shows  a  leucocyte  count  within 

the  normal,  but  revealing-  an  increased  proportion  of  eosino- 

24 


3/0  DISEASES  OF  THE  LUNGS  AND   PLEURAE 

phile  cells,  from  6  per  cent,  upwards.  Such  an  eosinophilia  is 
not,  however,  invariably  present,  nor  is  it  of  itself  diagnostic, 
since  it  is  observed  in  the  presence  of  other  animal  parasites,  as 
well  as  in  asthma  and  certain  diseases  of  the  skin.  The  comple- 
ment-fixation test,*  a  method  of  diagnosis  upon  the  lines  of  the 
Wassermann  reaction  for  the  detection  of  syphilis,  is  as  a  rule 
positive  in  echinococcus  disease,  but  even  with  the  best  tech- 
nique a  similar  result  has  occasionally  been  observed  in  the 
absence  of  such  affection.  A  negative  reaction  also  does  not 
exclude  the  presence  of  the  disease,  and  should  be  expected  if 
suppuration  of  the  cyst  has  taken  place.  The  reaction,  there- 
fore, cannot  be  entirely  relied  upon. 

The  removal  through  a  fine  trocar  of  the  characteristic 
hydatid  fluid  of  low  specific  gravity  (1005-1007),  rich  in 
chlorides  and  free  from  albumin,  containing  possibly  some 
booklets,  would  solve  the  diagnosis.-  This  step,  however, 
should  never  he  taken  until  the  surgeon  is  prepared  for  the 
rapid  evacuation  of  the  cyst,  and  this  for  reasons  to  be 
presently  mentioned. 

The  following  cases  illustrate  well  the  main  clinical  features 
presented  by  hydatid  of  the  lung  before  it  has  ruptured : 

Case  i. — Mr.  G.,  aged  about  thirty,  came  under  the  observation  of 
Dr.  Douglas  Powell  on  October  14,  1891,  on  account  of  a  cough  and 
sanguineous  expectoration.  He  was  a  well-developed  spare  man, 
who  had  lived  most,  if  not  all,  of  his  previous  life  in  Sydney.  He 
had  never  been  robust,  but  since  he  had  come  on  business  to  this 
country  in  1887  his  health  had  improved.  Two  years  previously  he 
had  influenza,  with  "  catarrh  of  the  right  lung,"  for  which  he  went 
to  St.  Leonards,  and  it  was  there  stated  to  him,  by  the  late  Dr.  Cooke, 
that  his  right  lung  was  weak,  but  not  definitely  diseased,  and  on 
examination  of  his  sputum  no  tubercle  bacilli  were  found.  He  re- 
gained health,  and  remained  well  through  the  winter  of  1890,  although 
he  again  found  it  expedient  to  spend  six  weeks  of  that  winter  at 
St.  Leonards,  his  own  home  being  in  or  near  Cambridge.  In  the 
spring  of  1891  he  caught  a  fresh  cold,  and  since  June,  when  he 
had  a  mild  pleurisy,  he  had  suffered  from  cough  and  morning  expec- 
toration, often  streaked  with  blood.  For  some  weeks  past  the 
expectoration  had  been  more  considerable,  diffused,  muco-purulent, 
and  more  or  less  stained  with  blood.  Specimens  of  the  sputum 
examined  on  October  15  and  17,  1891,  were  described  as  follows  : 
"  October  15  :  Purulent,  blood-stained;  no  tubercle  bacilli;  few  micro- 
organisms of  any  kind.  In  unstained  specimens  epithelial  debris, 
small  in  amount,  from  buccal-respiratory  tract.  October  17  :  Two 
samples    having    the    same    character ;    purulent,    blood-stained ;    no 


HYDATID   DISEASE  OF  THE  LUNGS 


371 


tubercle  bacilli ;  in  unstained  specimens  pus  cells,  many  undergoing 
fatty  degeneration,  also  large  lymph  cells  degenerated;  large  zooglcea 
groups  of  micrococci;  very  few  epithelial  elements." 

The  physical  signs  are  shown  in  the  annexed  diagram  (Fig.  35). 
Some  fulness  was  observed  on  the  right  front  of  the  chest  from  the 
second  to  the  sixth  rib-space ;  over  this  area,  and  extending  laterally 
to  the  anterior  axillary  line  and  to  the  left  margin  of  the  sternum, 
the  percussion  note  was  dull  in  the  centre,  shading  off  at  the  margin, 
so  as  to  present  a  rounded  outline.  Over  the  dull  space  the  respiratory 
murmur  was  annulled,  vocal  fremitus  diminished,  and  voice  not  con- 
ducted.    Along    the    upper   margin    of    dulness,    in    the   subclavicular 


B  A- 


FiG.  35. 

A,  Centre  of  dense  dulness  and  fulness  of  surface;  B,  area  of  lighter  dul- 
ness, with  annulled  breath-sound  and  fremitus  marking  limits  of 
tumour ;  C,  shell  of  lung,  giving  high-pitched  resonance,  weak  respira- 
tion, and  a  few  fine  rales ;  D,  liver  dulness,  between  which  and  area 
of  tumour  there  is  a  narrow  zone  of  resonant  lung,  giving  weak 
but  vesicular  breath-sound;  E,  heart's  apex-beat  a  little  to  left  of  the 
'      normal. 


regions,  the  percussion  note  was  high-pitched,  tubular,  and  the 
respiratory  murmur  weak  and  accompanied  by  a  few  fine  rales.  At 
the  lower  border,  between  it  and  the  liver  dulness,  there  was  also  a 
narrow  area  of  resonance  and  weak  but  vesicular  breath-sound.  The 
left  lung  was  enlarged  to  include  the  left  half  of  the  sternum  and 
covering  the  precordial  region.  The  heart's  apex-beat  was  slightly 
to  the  left  of  the  normal  point.  Posteriorly,  on  the  right  side,  the 
respiration  was  weakened  over  the  upper  half,  with  some  fine  conges- 
tion rales  at  the  extreme  apex,  and  some  similar  rales  at  the  base ; 
the  percussion  note  in  the  interscapular  region  was  slightly  raised. 
The  diagnosis  of  hydatid  of  the  lung  having  been  made,  aspiration, 


3/2  DISEASES   OF   THE   LUNGS   AND   PLEURA 

at  that  time  a  recognised  method  of  treatment,  was  advised,  and  this 
was  performed  between  the  fourth  and  fifth  ribs  by  the  late  Dr.  Lucas, 
of  Cambridge,  on  November  4,  one  pint  of  clear  hj'datid  fluid  being 
removed  by  the  instrument.  Five  minutes  later  another  pint  tinged 
with  blood  came  with  a  rush  from  the  throat,  and  for  some  days 
afterwards  Mr.  G.  had  a  bad  cough,  spitting  up  cyst  membrane  and 
foetid  pus.  The  expectoration  for  some  weeks  amounted  to  a  pint 
and  a  half  each  day,  .but  gradually  diminished  to  half  a  pint,  then 
ceased. 

When  seen  again  on  February  9,  1892,  he  had  no  cough,  his  general 
condition  was  good,  and  he  was  again  on  his  way  to  St.  Leonards. 
There  was  slight  fulness  and  want  of  resonance  in  the  right  second 
space ;  otherwise  nothing  was  notable  beyond  some  weakness  and 
harshness  of  breath-sound.  Dr.  Lucas,  in  a  letter  dated  December  12, 
1892,  reported  him  as  being  in  robust  health. 

Case  2. — Mr.  X.,  aged  twenty-three,  was  born  in  New  Zealand 
and  had  lived  there  all  his  life  until,  in  September,  19 16,  he  left  for 
England  as  a  member  of  the  New  Zealand  Expeditionary  Force.  He 
was  a  healthy,  well-grown  man,  and  had  always  enjoyed  good  health. 
He  had  previously  been  engaged  in  office  work. 

His  illness  commenced  in  March,  1917,  when  serving  in  France. 
The  first  symptom  complained  of  was  pain  in  the  lower  part  of  the 
left  side,  accompanied  by  slight  pyrexia  lasting  for  a  few  days.  This 
was  followed  by  cough  with  phlegm,  which  was  sometimes  streaked 
with  blood.  These  symptoms  continued,  and  on  June  2  he  had  a  sharp 
attack  of  haemoptysis,  and  on  June  13  a  second  attack,  on  this  occasion 
bringing  up  several  ounces  of  blood.  Except  for  the  slight  and  passing 
pyrexia  referred  to  above  there  had  been  no  rise  of  temperature.  The 
sputum  was  examined  for  tubercle  bacilli,  but  they  were  not  found. 

He  was  invalided  home  to  England  and  admitted  to  a  base  hospital, 
when  the  diagnosis  of  pulmonary  tuberculosis  was  made  and 
sanatorium  treatment  recommended.  He  was,  however,  transferred 
to  the  New  Zealand  General  Hospital  at  Walton-on-Thames,  where 
the  possibility  of  hydatid  disease  was  recognized,  in  view  of  the 
frequent  occurrence  of  this  malady  in  the  Dominion,  and  on  being 
X-rayed  the  regular,  well-defined  shadow  of  the  C3'st  was  at  once  seen, 
thus  confirming  the  diagnosis. 

On  June  29,  through  the  courtesy  of  Colonel  Myers  and  of  the 
New  Zealand  Authorities,  one  of  us  had  the  opportunity  of  visiting 
the  hospital  at  Walton-on-Thames,  in  which  at  the  time  were  five 
cases  of  hydatid  of  the  lung,  and  found  the  physical  signs  in  the 
case  of  Mr.  X.  to  be  as  follows  :  On  the  front  of  the  chest  percussion 
and  auscultation  were  natural.  On  the  back  a  somewhat  oval  area 
of  dulness  was  present,  involving  the  lower  scapular  and  interscapular 
region  on  the  left  side,  extending  from  the  fourth  to  the  eighth  rib 
posteriorly,  as  indicated  at  A,  Fig.  36.  For  some  distance  around"  this 
the  note  was  flattened  (B,  Fig.  36),  but  below  this  to  the  bottom  of 


HYDATID   DISEASE  OF  THE  LUNGS 


373 


the  chest  the  percussion  note  was  resonant.  Over  the  dull  area  the 
vesicular  murmur  was  but  feebly  heard,  and  vocal  vibration  was 
diminished.  No  bronchial  breathing  or  moist  sounds  were  audible.  On 
examination  the  patient  with  the  X-ray  screen,  a  well-defined  shadow 
the  size  of  a  cocoanut,  with  regular  outline,  having  all  the  appearance 
of  a  hydatid  cyst,  was  clearly  visible.  From  its  better  definition  when 
viewed  from  behind,  it  was  clear  that  the  cyst  was  nearer  the  posterior 
than  the  anterior  wall  of  the  chest,  thus  agreeing  with  the  physical 


signs. 


The  diagnosis  having  been  made,  it  was  decided  to  treat  the  case 
by  resection  of  rib  and  drainage,  as  described  in  a  further  paragraph 
(see  p.  377).  The  operation  was  successfully  performed  on  June  30, 
and  on  August  8  Mr.  X.  was  evacuated  home  to  New  Zealand,  con- 
valescence being  somewhat  retarded  by  infection  of  the  wound,  which 
manifested  itself  a  week  after  the  operation. 


Fig.  36. — Diagram  showing  the  Physical  Signs  of  Hydatid  of  the  Lung 
AS  met  with  in  Mr.  X.,  aged  Twenty-three,  whose  Case  is  described 
IN  THE  Text. 

2.  Rupture  of  the  Cyst. — Spontaneous  rupture  of  the  cyst 
into  the  bronchial  tubes  takes  place  in  about  half  the  cases,  into 
the  pleura  in  5  per  cent.,  and  more  rarely  into  the  pericardium, 
pulmonary  vein  (Wilson  Fox),  or  through  the  diaphragm 
(Dupuytren).  It  must  be  remembered  also  that  an  hydatid 
cyst  of  the  liver  may  rupture  upwards  and  the  contents  be 
expectorated. 

Sudden  pain,  intense  dyspnoea,  and  the  expectoration  of  a 
large  amount  of  watery  blood-stained  fluid,  often  having  a 
peculiar  and  unpleasant  taste,  are  the  symptoms  which  imme- 
diately attend  upon  rupture  of  the  sac  into  the  lung.  In  some 
cases  the  lungs  are  so  completely  flooded  as  to  overwhelm  the 
patient  and  cause  immediate  death.    In  other  cases  the  churn- 


374  DISEASES   OF  THE  LUNGS  AND   PLEURA 

ing  and  rattling  of  the  fluid  and  air  in  the  chest  can  be  heard, 
and  after  a  desperate  struggle  the  bronchial  tubes  become 
sufficiently  cleared,  when  rapid  amendment  of  symptoms  takes 
place.  Together  with  the  fluid  a  greater  or  smaller  number  of 
daughter  cysts  may  be  expelled,  and  sometimes  immediately, 
but  more  often  at  a  subsequent  date,  the  cyst  wall  may  be 
expectorated  entire,  or  more  commonly  in  fragments,  with 
symptoms  of  threatened  suffocation.  In  some  cases  death  has 
resulted  from  impaction  of  a  portion  of  the  cyst  wall  in  the 
glottis.  It  frequently  happens  that  with  these  alarming- 
symptoms  the  real  nature  of  the  disease  is  for  the  first  time 
disclosed,  the  expectoration  of  the  hydatid  membrane  or 
daughter  cysts  being  especially  characteristic. 

Hooklets  and  scolices  are  frequently  to  be  found  in  the 
expectorated  fluid  on  microscopical  examination,  and  frag- 
ments of  the  cyst  membrane  reveal  also  the  peculiar  lamination 
so  characteristic  of  hydatid,  which  remains  unchanged  long 
after  the  death  of  the  parasite. 

Haemoptysis,  much  more  profuse  in  quantity  than  in  the 
earlier  stages  of  the  disease,  may  occur  at  the  time  of  rupture, 
or  at  a  subsequent  period.  It  is  due  to  the  tearing  away  of  the 
cyst  membrane  from  its  vascular  capsule,  from  which,  at 
the  moment  of  collapse,  the  support  and  even  pressure  of  the 
distended  cyst  is  suddenly  removed.  This  intracystic  pressure 
was  ascertained  by  Dr.  Thomas  ^*  in  several  cases  of  hydatid 
cyst  to  measure  from  lo  to  12  inches  of  water,  and  in  one  case, 
in  which  the  cyst  was  large  enough  to  bulge,  and  was  therefore 
compressed  by  the  thoracic  wall,  it  amounted  to  25  inches 
during  inspiration,  30  inches  during  expiration.  Haemoptysis 
is  thus  one  of  the  most  constant  and  important  symptoms  of 
hydatid  of  the  lung,  occurring  at  some  period  in  about  four- 
fifths  of  the  cases.  As  a  rule  only  slight  in  degree  at  the 
earlier  stages,  it  is  often  severe  and  repeated,  sometimes  even 
fatal,  after  the  rupture  of  the  sac. 

Course  of  the  Disease. — From  time  to  time,  as  we  have 
indicated,  small  hydatid  cysts  are  unexpectedly  met  with  in  the 
lung  after  death,  shrivelled  and  infiltrated  with  salts,  and  with 
their  fluid  contents  partially  absorbed  and  inspissated.  But 
such  instances  of  the  death  of  the  parasite,  though  not  infre- 
quent in  the  liver,  are  rare  in  the  lung,  and  only  occur  in  cysts 
of  very  small  dimensions,  which  have  probably  given  rise  to 


HYDATID   DISEASE  OF  THE  LUNGS  3/5 

no  symptoms.  Dr.  Lendon/*  indeed,  goes  so  far  as  to  say 
that  there  is  "  no  case  on  record  in  which  a  cyst  diagnosed  as 
such  during  life  has  been  left  alone,  and  has  been  found  after 
the  death  of  the  patient  to  have  undergone  retrograde  change." 
In  considering  treatment,  therefore,  such  a  happy  event  must 
not  be  anticipated.  Hydatid  cysts,  indeed,  large  enough  to 
give  rise  to  symptoms  and  physical  signs,  and  to  be  diagnosed 
as  such,  tend  to  enlarge,  and  finally  to  rupture,  exposing  the 
patients  in  that  event  to  the  danger  of  being  suffocated  by 
the  sudden  flooding  of  the  bronchial  tubes. 

Of  the  large  proportion  of  cases  in  which  death  is  not  caused 
by  suffocation  at  the  time  of  rupture,  many  recover;  the  cyst 
wall  is  gradually  expectorated,  and,  the  surrounding  lung 
expanding,  the  cavity  becomes  closed.  In  other  cases,  after 
a  longer  or  shorter  interval,  suppuration  of  the  capsule  takes 
place,  and  a  pulmonary  abscess,  sometimes  of  a  very  foetid 
type,  results. 

The  emaciation,  hectic,  occasional  haemoptysis,  severe  cough, 
and  often  profuse  expectoration  that  characterise  the  later 
stages  of  hydatid  disease,  in  combination  with  the  physical 
signs  of  excavation  of  the  lung  and  of  great  bronchial  irrita- 
tion, especially  on  the  side  affected  by  the  parasite,  are  at  first 
sight  suggestive  of  advanced  pulmonary  tuberculosis.  A 
careful  examination  into  the  history  of  the  case,  however, 
including  the  sudden  commencement  of  expectoration  as  a 
copious  outburst  of  blood-stained  watery  or  semi-purulent 
fluid,  having  a  peculiar  and  unpleasant  taste,  and  the  discovery 
of  the  physical  signs  of  a  cavity  in  some  situation  unusual  in 
phthisis,  will  arouse  suspicions  as  to  the  true  nature  of  the 
disease.  A  careful  daily  observation  of  the  sputum,  which  is, 
moreover,  often  foetid,  may  lead  to  the  discovery  of  mem- 
branous shreds  or  the  more  typical  "  gooseberry  skins,"  of 
which  microscopic  examination  will  reveal  the  structure  to  be 
that  of  hydatid  cyst. 

Diagnosis. — From  the  early  occurrence  of  haemoptysis  and 
cough  hydatid  disease  of  the  lung  may  be  mistaken,  as  we  have 
seen,  for  phthisis.  If  situated  in  the  lower  part  of  the  lung  it 
may  simulate  a  pleuritic  effusion,  and  the  more  so  as  some 
degree  of  pleurisy  with  slight  effusion  not  uncommonly 
accompanies  the  cyst-formation,  though  not,  as  a  rule, 
suflficient  to  obscure  the  X  ray  picture. 


3;6  DISEASES   OF  THE  LUNGS   AND  PLEURA 

The  possibility  of  hydatid  affection  should  be  borne  in  mind 
in  patients  coming  from  Australia  and  New  Zealand  or  any 
country  in  which  the  malady  is  common,  and  an  X-ray 
examination  of  the  chest  should  be  made  in  all  doubtful  cases. 

In  the  later  stages  of  the  disease,  when  suppuration  has 
occurred,  the  case  has  to  be  discriminated  from  advanced 
phthisis,  suppuration  of  the  lung,  and  other  alHed  conditions. 
A  repeated  examination  of  the  sputum  is  then  of  great  value. 

Treatment. — A  review  of  the  statistics  of  cases  left  untreated 
would  place  the  natural  mortahty  of  the  complaint  at  between 
50  and  60  per  cent.^  The  disease  cannot,  therefore,  be  left 
alone,  and  medicinal  remedies  being  of  little  use,  recourse 
must  be  had  to  more  active  methods  of  treatment. 

Until  recently,  paracentesis  of  the  cyst  and  the  evacuation  of 
as  much  of  its  fluid  contents  as  possible,  thus  causing  the  death 
of  the  parasite,  was  the  method  usually  employed.  Under  this 
line  of  treatment  certain  cases  no  doubt  recovered  which  under 
the  expectant  treatment  would  have  died,  but  in  some  cases 
death  has  directly  followed  the  operation*^  (Plate  XXI.).  This 
arises  in  certain  instances  from  the  trocar  becoming  blocked  by 
a  portion  of  the  cyst  wall  or  by  a  daughter  cyst,  and  failing 
therefore  to  extract  more  than  a  few  ounces  of  fluid ;  when  the 
instrument  is  withdrawn,  the  elastic  cyst  retracts,  and  the 
contents  are  discharged  into  the  cavity  in  which  it  lies,  thus 
flooding  the  bronchi  and  leading  to  suffocation,  as  in  spon- 
taneous rupture.*  In  other  cases  it  is  probable  that  the 
paracentesis  produces  not  merely  a  fine  hole  in  the  cyst  wall, 
but  a  tear  in  the  chitinous  envelope,  thus  more  easily  leading 
to  the  escape  of  the  contained  fluid. 

For  the  above  reasons  paracentesis  can  no  longer  be  recom- 
mended, and  we  should  in  all  cases  in  which  the  cyst  is 
accessible  proceed  at  once  to  the  radical  operation  of  incision 
and  removal,  which  constitutes  the  proper  treatment  of  such 
cases.  For  similar  reasons,  exploratory  puncture  for  diag- 
nostic purposes,  even  with  the  finest  needle,  should  not  be 
countenanced  until  resection  of  a  rib  has  been  performed  and 
the  surgeon  is  ready  at  once  to  incise  the  cyst.     Moreover, 

*  It  is  interesting  to  note  that  the  blocking  of  the  trocar  by  a  cyst 
during  paracentesis  was  a  condition  well  known  to  ancient  writers  (see 
Aretaeus,  On  the  Causes  and  Symptoms  of  Chronic  Diseases,  book  ii., 
chap,  i.,  p.  337,  Sydenham  Society  edition). 


PLATE   XXI 


,U>^-' 


i.ox 


HYDATID  OF  THE  LUNG 

The  drawing  shows  the  left  lung  of  a  boy  aged  nine  years.  In 
the  lower  lobe  is  seen  a  lajrge  cavity  about  three  inches  in 
diameter,  in  which  lies  collapsed  and  coiled  up  a  solitary  hydatid 
cyst  (A).  From  the  cavity  a  communication  with  the  left 
bronchus  had  been  effected  by  an  ulcerated  aperture,  through 
which  a  bristle  has  been  passed.  By  this  means  the  fluid  within 
the  hydatid  made  its  way  into  the  bronchial  tract  after  puncture 
of  the  cyst,  and  caused  death  by  suffocation.  The  pleura  over 
the  outer  aspect  of  the  cyst  is  covered  with  recent  lymph. 

From  a  patient  who  presented  symptoms  and  signs  suggestive 
of  pleurisy  with  effusion.  Paracentesis  was  performed,  but  only 
a  few  drachms  of  clear  watery  fluid  were  evacuated.  The  boy 
almost  immediately  began  to  cough,  and  brought  up  3  or  4  ounces 
of  clear  frothy  fluid.  He  died  of  suffocation  within  eight  minutes 
of  the  paracentesis.  The  case  is  recorded  by  the  late  Dr. 
Bristowe  in  the  Transactions  of  the  Clinical  Society,  ,1891, 
vol.  xxiv.,  p.  73. 


(From  the  Museum  of  St.   Thomas's  Hospital.     |  natural  size.) 


PLATE  XXI 


-     A 


Hydatid  of  the  Lung. 


To  face  p.  376. 


HYDATID   DISEASE  OF  THE  LUNGS  377 

since  the  introduction  of  the  X-rays  exploratory  puncture  has 
become  unnecessary,  for  hydatid  cysts  present,  as  we  have 
said,  a  picture  which  is  strongly  suggestive  of  the  disease. 

Operation  having  been  decided  upon,  resection  of  a  rib 
must  be  performed  and  the  pleural  layers  united  by  suture. 
The  cyst  must  be  then  boldly  and  freely  opened  with  the  aid  of 
expanding  forceps,  and  its  fluid  contents  allowed  to  escape 
quickly,  to  avoid  the  flooding"  of  the  lung  which  might  other- 
wise result.  To  assist  the  evacuation,  it  is  wise  to  turn  the 
patient  well  over  on  to  the  affected  side  at  the  moment  of 
incising  the  cyst.  The  chitinous  envelope  can  as  a  rule  be 
easily  detached  from  the  surrounding  lung  and  the  cyst  with- 
drawn. The  wall  of  the  cavity  should  then  be  swabbed  with  a 
I  per  cent,  solution  of  formalin  to  render  it  aseptic,  and  thus 
prevent  post-operative  recurrence  from  the  growth  of  an 
escaped  scolex.^  The  cavity  and  wound  in  the  chest-wall  may 
then  be  closed,  but  should  it  prove  impossible  to  evacuate  the 
cyst,  or  should  suppuration  have  occurred,  drainage  must  be 
undertaken.  The  results  of  this  method  of  treatment  are  very 
satisfactory.  To  quote  only  those  of  more  recent  date,  we  find 
that  of  99  cases  reported  upon  by  Garre  and  Quincke,*  78 
recovered  and  21  died,  a  mortality  of  21 '2  per  cent. 
Guimbellot,'  collecting  cases  from  the  literature,  found  that 
among  223  patients  treated  by  thoracotomy,  194  were  cured 
and  29  died,  a  death-rate  of  13  per  cent.  Dividing  the  cases 
into  those  in  which  the  cyst  was  healthy  at  the  time  of  the 
operation,  and  those  in  which  suppuration  had  occurred,  the 
statistics  yielded  a  mortality  of  8'2  per  cent,  in  the  case  of 
the  former,  and  of  19  per  cent,  in  the  latter.  These  figures 
contrast  favourably  with  the  death-rate  of  55  per  cent,  among 
patients  left  untreated.  The  value  of  radical  surgical  treat- 
ment as  indicated  by  the  earlier  statistics  of  Dr.  Thomas-* 
is  thus  amply  demonstrated. 

Should  spontaneous  rupture  occur,  each  case  must  be  treated 
on  its  merits.  As  we  have  seen,  many  such  patients  eventually 
recover,  gradually  coughing  up  the  membrane  and  evacuating 
the  cyst.  But  if  suppuration  has  set  in,  and  if,  in  spite  of  a 
generous  supporting  diet  and  the  administration  of  such 
remedies  as  bark  and  mineral  acids,  the  patient  is  evidently 
losing  ground  from  hectic  and  profuse  expectoration,  it  will  be 
wise  to  treat  the  case  surgically,  and  to  open  and  drain  the 


3/8  DISEASES   OF  THE  LUNGS   AND   PLEUR/E 

cavity  on  the  lines  already  indicated  for  abscess  of  the  lung 
(see  p.  361). 

If  the  hydatid  cyst  be  in  the  pleural  cavity,  a  condition  of 
rare  occurrence,  it  will  probably  be  mistaken  for  a  pleural 
effusion  until  exploratory  puncture  reveals  the  true  nature  of 
the  case.  Resection  of  a  rib  and  evacuation  of  the  cyst  is  then 
the  proper  method  of  treatment. 


REFERENCES. 

'  la)  Hydatid  Disease,  by  John  Davies  Thomas,  M.D.,  F.R.C.S.,  p.  122. 
Adelaide,   1884. 
{b)  Loc.  cit.,  p.  21. 

^  [a)  Hydatid  Disease,  by  the  late  John  Davies  Thomas,  M.D.,  F.R.C.S., 
edited   by   Alfred   Austin   Lendon,    M.D.,    vol.    ii.,    p.    38,    Sydney, 
1894. 
[b]  Loc.  cit.,  vol.  ii.,  pp.   142,   160,  161. 

°  [a]  See  Clinical  Lectures  on  Hydatid  Disease  of  the  Lungs,  by  Alfred 
Austin  Lendon,  M.D.,  p.   116.     London,  1902. 
{b)  Loc.  cit.,  p.  23. 

^  [a]    See   L.    C.    Zapelloni    (//  Policlinico,    Rome,    1915,    sez.    Chirurg., 
xxii.),  British  Medical  Journal,  1916,  i.,  Epit.  No.  29. 
{b)  Injection,  Immunity,  and  Specific  Therapy,  by  John  A.    Kolmer, 
M.D.,  D.Ph.,  M.Sc,  p.  524.     Philadelphia  and  London,   1917. 

'  The  Surgery  of  the  Chest,  by  Stephen  Paget,  M.A.,  F.R.C.S.,  p.  411. 
Bristol  and  London,   1896. 
^  See,  amongst  others  : 

(i)  "  Case  of  Living  Hydatid  of  the  Lung,  in  which  Aspiration  was 
followed  immediately  by  Subcutaneous  Emphysema  and  by  Suffoca- 
tion due  to  the  Rush  of  Hydatid  Fluid  into  the  Bronchial  Tubes," 
by  J.  S.  Bristowe,  M.D.,  F.R.S.,  Transactions  of  the  Clinical  Society 
of  London,   1891,  vol.  xxiv.,  p.  73. 

(2)  A  "  Case  of  Hydatid  of  Lung  which  proved  Fatal  by  Rupture  into 
a  Bronchus  Nine  Hours  after  Treatment  by  Aspiration,"  by  Hector 
W.  G.  Mackenzie,  M.D.,  Transactions  oj  the  Clinical  Society  of 
London,   1S92,  vol.  xxv.,  p.   215. 

'  "  Observations  on  the  Treatment  of  Hydatid  Disease  from  the  Points 
of  View  of  (i)  Prophylaxis,  (2)  Aspiration  or  Tapping,  and  (3)  the 
No-Drain  Operation  of  Bond  and  Others,"  by  L.   E.   Barnett,   F.R.C.S., 

Professor  of  Surgery,  University  of  Otago,  New  Zealand  Medical  Journal, 
May,   1914,  p.   145. 

*  Surgery  of  the  Lung,  by  C.  Ga.rre  and  H.  Quincke,  second  edition. 
Translated  from  the  German  by  David  M.  Barcroft,  M.D.,  p.  214.  Lon- 
don, 1912. 

'  Sur  le  Traitement  Chirurgical  des  Kystes  Hydatiques  de  la  Plevre 
et  du  Poumon.  These  pour  le  Doctorat  en  Medecine,  par  Marcel 
Guimbellot,  p.   40.     Paris,    1910. 


CHAPTER   XXIV 

INTRATHORACIC  DERMOID  TUMOURS 

Sir  John  Bland-Sutton*  classifies  those  dermoid  tumours  as 
"  sequestration  dermoids,"  which  arise  in  detached  or  se- 
questrated portions  of  surface  epithehum.  They  occur  chiefly 
in  situations  where,  during  embryonic  life,  coalescence  takes 
place  between  skin-covered  parts,  namely,  along  the  median 
line,  in  front  or  behind.  The  thoracic  dermoids  of  this  type 
occur  in  two  situations  :  — 

(i)  On  the  anterior  aspect  of  the  sternum,  usually  in  the 
middle  line,  about  the  junction  of  the  first  and  second  sternal 
pieces,  where  they  present  as  external  tumours. 

(2)  In  the  thoracic  cavity. 

Sir  John  Bland-Sutton  would  regard  such  intrathoracic 
dermoids  as  due  to  the  sequestration  of  a  piece  of  skin  during 
the  development  and  junction  of  the  two  halves  of  the  sternum, 
and  the  subsequent  dislocation  backwards  of  the  involved 
portion  to  the  deep  surface  of  the  bone.  Here  it  may  remain 
indefinitely  dormant,  or  become  active  and  gradually  enlarge 
to  form  a  cystic  tumour.  Such  cysts  are  probably  always 
mediastinal  in  their  commencement,  and  may  so  remain 
throughout  their  course.  In  other  cases  the  tumours  rapidly 
enlarge,  extending  their  boundaries,  not  passively  by  mere 
distension  from  within  of  accumulating  contents,  but  actively, 
so  that  the  term  dermoid  growth,  rather  than  dermoid  cyst, 
should  be  applied  to  them.  As  they  enlarge  they  are  apt  to 
become  closely  adherent  to  the  pericardium  and  pleura  and 
to  penetrate  deeply  into  the  lung,  where  they  become  so 
embedded  that  their  original  connection  with  the  mediastinum 
is  obscured.  A  communication  with  the  lung  or  a  bronchus 
may  at  any  time  be  established,  and  on  the  accession  of  air  into 
the  cavity  suppuration  is  liable  to  ensue. 

On  section,  such  tumours  are  found  to  contain  sebaceous 
material,  and  often  hairs.     In  other  cases  the  cyst  contains  in 

379 


380  DISEASES   OF  THE  LUNGS   AND   PLEURA 

addition  such  structures  as  muscle,  cartilage,  bone  or  teeth, 
and  would  then  belong  pathologically  to  a  different  category, 
and  should  be  classified  among  the  teratomata. 

Intrathoracic  dermoids,  including  teratomata,  are  very  rare, 
and  Dr.  Batty  Shaw  and  Dr.  Williams,-''  in  their  paper  dealing 
with  this  subject,  were  only  able  to  find  records  of  thirty-five 
authentic  cases,  a  total  recently  brought  up  to  fifty-two  by 
Dr.  Pohl.^  From  an  analysis  of  these  cases  the  following  facts 
appear. 

The  sexes  are  affected  equally.  In  some  of  the  cases  the 
tumour  has  remained  of  small  size  and  has  been  only  found  by 
accident  after  death.  In  others  symptoms  have  supervened 
which  caused  the  patient  to  seek  advice.  The  age  at  which 
such  symptoms  manifest  themselves  varies,  being  sometimes  as 
early  as  sixteen,  though  "  in  by  far  the  larger  number  the  age 
was  between  twenty  and  thirty  years."  Careful  cross-question- 
ing may,  however,  elicit  the  fact  that  hairs  have  been  ex- 
pectorated for  some  years  previously;  this  had  occurred  in  one 
case  on  many  occasions  since  the  patient  was  sixteen  years  of 
age,  and  in  another  at  fifteen,  the  earliest  age  at  which  it  has 
been  recorded.  This  symptom,  which  was  present  in  seven  of 
the  thirty-five  cases  referred  to  above,  is  a  most  characteristic 
feature  of  the  disease,  and  should  always  be  carefully  inquired 
for.  It  is  of  importance  also  as  showing  that  a  communication 
exists  between  the  interior  of  the  cyst  and  the  air-passages, 
with  the  danger  of  suppuration  which  such  a  communication 
entails. 

Other  symptoms,  such  as  cough,  expectoration,  shortness  of 
breath,  and  sometimes  haemoptysis,  are  produced  by  the 
enlargement  and  irritating  effects  of  the  cyst,  which  not 
uncommonly  reaches  the  size  of  a  child's  head,  or  even  larger. 
The  temperature  is  as  a  rule  but  little  raised,  unless  suppura- 
tion or  septic  pneumonia  ensue.  Fever,  night-sweating,  and 
wasting  then  supervene.  In  some  cases,  as  in  that  to  be 
immediately  related,  an  empyema  occurs,  and  may  entirely 
mask  any  characteristic  signs. 

The  physical  signs — impairment  of  note  over  the  tumour, 
with  weak  or  absent  breath-sounds,  diminished  vocal  resonance 
and  vocal  vibrations — offer  nothing  characteristic.  It  is  stated 
that  compression  of  veins  is  much  less  common  than  in  cases 
of  malignant  growth  in  the  mediastinum,  a  point  of  some 


INTRATHORACIC   DERMOID   TUMOURS  38 1 

diagnostic  importance.  It  occurred,  however,  in  a  marked 
degree  in  a  case  reported  by  Dr.  Mouat.* 

The  X-rays,  provided  the  surrounding  lung  and  pleura  be 
still  healthy,  reveal  a  somewhat  rounded  shadow,  with  margin 
well  defined,  except  perhaps  on  the  inner  side,  and  without 
pulsation.  Such  a  picture  might  lead  the  observer  to  consider 
the  possibility  of  a  dermoid  cyst,  but  in  the  absence  of  the 
expectoration  of  hairs,  or  of  an  exploratory  operation,  the 
exact  diagnosis  must  remain  a  matter  of  uncertainty. 

The  disease,  if  untreated,  marches  slowly  to  a  fatal  termina- 
tion, more  than  half  the  patients  dying  before  the  age  of  thirty. 
The  end  is  brought  about  by  suppuration,  septic  pneumonia, 
pulmonary  tuberculosis,  and  sometimes  with  symptoms  of 
pressure ;  in  other  cases  the  cysts  have  been  known  to  rupture 
into  the  pericardium  and  the  superior  vena  cava.  The  average 
age  at  death  in  seventeen  cases  collected  by  Drs.  Batty  Shaw 
and  Williams""  was  thirty-two,  the  youngest  patient  being 
twenty,  the  oldest  sixty. 

Drugs  are  of  no  avail  in  the  treatment  of  this  disease,  and 
surgical  intervention  must  be  considered.  Of  seven  cases  thus 
treated,  quoted  by  the  above  authors,  in  one,  in  which  the  cyst 
was  small,  complete  enucleation,  with  recovery  of  the  patient, 
was  effected.  But  such  a  result  is  exceptional.  In  most  cases, 
before  the  cyst  has  given  rise  to  decided  symptoms,  and  thus 
come  under  observation,  it  has  already  attained  considerable 
dimensions,  and  has  formed  attachments  to  the  pericardium, 
lungs,  pleura,  or  diaphragm,  so  that  its  complete  removal  is 
impossible.  For  a  similar  reason  complete  retraction  of  the 
cyst  walls  after  operation  is  unlikely.  Nevertheless,  greajt 
diminution  in  size  of  the  cavity  has  followed  incision  and 
drainage  in  most  of  the  cases  operated  upon,  the  patient  being 
left  with  a  small  fistula  only.  In  one  case  alone,  and  that  the 
earliest,  was  the  result  unsatisfactory. 

In  view,  therefore,  of  the  steady  progress  of  the  disease  to  a 
fatal  termination,  if  not  actively  treated,  the  question  of 
surgical  intervention  should  always  be  carefully  considered. 

The  details  of  the  following  case,  sent  to  Dr.  Douglas  Powell 
by  the  late  Dr.  Sturges,  of  Beckenham,  and  seen  by  him  six 
years  later  with  the  late  Sir  Lauder  Brunton  and  Sir  Rickman 
Godlee,  will   illustrate  the   more   important  features    of  the 


382  DISEASES   OF   THE   LUNGS   AND   PLEURA 

disease,  althovigh,  as  we  shall  presently  point  out,  in  view  of 
later  investigations  there  is  some  room  for  doubt  whether  its 
real  origin  may  not  have  been  teratomatous.  In  this  instance 
it  will  be  noticed  that  but  little  retraction  of  the  cavity  took 
place  after  operation. 

At  the  first  consultation  in  1881,  the  lady,  aged  twenty-nine,  pre- 
sented all  the  signs  and  symptoms  of  a  purulent  effusion  into  the 
right  pleura,  which  had  supervened  upon  an  acute  right  pleurisy 
the  preceding  May.  There  were  no  physical  signs  to  differentiate  the 
case  from  an  ordinary  empyema,  the  presence  of  pus  being  inferred 
from  the  prolonged  duration  and  hectic  character  of  the  symptoms. 
Exploration,  with  a  view  to  thoracentesis,  was  advised,  but  was 
deferred,  as  the  lady  was  on  her  way  to  the  South  of  France.  The 
operation  was  then  still  further  postponed,  and,  a  few  months  later, 
rupture  through  a  bronchus  took  place,  and  a  large  quantity  of 
matter  was  expectorated.  The  empyemic  cavity  partially  contracted, 
the  expectoration  gradually  diminished,  and  the  lady  regained  strength 
and  flesh,  and  subsequently  married. 

Mrs.  W.  was  not  seen  again  by  Dr.  Powell  until  six  years  later,  in 
June,  1887,  when  Sir  Lauder  Brunton  consulted  him  about  her,  she 
having  somewhat  failed  of  late,  losing  flesh,  showing  a  daily,  although 
slight,  rise  of  temperature,  and  presenting  a  trace  of  albumin  in  the 
urine.  The  side  was  now  considerably  contracted,  the  ribs  approxi- 
mated, and  the  signs  of  the  empyemic  cavity  occupied  the  antero- 
lateral region  of  the  lower  right  chest,  extending  also  somewhat  back- 
wards, where  it  was  bounded  above  by  a  downwartf  slanting  line 
skirting  the  angle  of  the  scapula.  There  was  still  nothing  about  the 
case  to  suggest  any  other  diagnosis  than  that  of  an  old  empyema 
cavity  communicating  with  the  lung  through  a  bronchial  fistula.  It 
was  agreed  that  the  cavity  should  be  drained  from  without,  and,  on 
June  18,  this  was  effected  by  Sir  RIckman  Godlee,  who  excised  a 
portion  of  the  sixth  rib  in  the  anterior  axillary  line,  having  previously 
punctured  at  this  point,  where  there  was  some  tenderness,  and  found 
pus.  About  an  ounce  of  pus  escaped,  and  some  caseous,  putty-like- 
looking  stuff  was  removed.  The  patient  again  improved,  but  the 
discharge  from  the  wound  continued. 

On  August  9  the  cavity  was  again  explored.  At  Its  orifice  a  hair 
was  noticed,  and  on  introducing  a  small  sponge  into  the  cavity  a 
number  of  hairs  were  found  to  adhere  to  it,  and  subsequently  a 
handful  of  matted  hairs  and  putty-like  debris  was  removed.  The 
nature  of  the  case  was  now  for  the  first  time  apparent,  and  the 
patient,  on  being  questioned,  stated  that  she  had  coughed  up  two 
hairs  since  the  previous  operation,  and  also  on  one  or  two  occasions 
long  previously,  and  that  her  brother,  who  had  been  dressing  the 
wound,  had  observed  one  or  two  on  the  dressings.  On  carefully 
exploring  the  cavity  In  the  light  of  this  new  discovery,  its  irregular 
interior  was  found  to  be  due  to   finger-like  processes   consisting  of 


INTRATHORACIC  DERMOID  TUMOURS  383 

excrescences  of  fibro-cellular  tissue  covered  with  skin,  from  which 
the  hairs  were  growing.  At  a  subsequent  operation  in  September 
the  opening  was  enlarged  by  excising  a  portion  of  a  third  rib,  and 
one  of  these  processes  was  removed  close  to  its  base  by  Paquelin's 
cautery,  and  other  small  ones  ligatured  and  removed  by  scissors.* 
It  was  found  that  the  cavity  extended  up  to  the  apex  of  the  thorax, 
and  that  the  wall  of  the  cyst  was  intimately  connected  with  the 
surfaces  of  the  lung  and  diaphragm.  The  internal  parts  were  some- 
what freely  cauterised,  and  the  skin  of  the  thorax  was  then  sutured 
to  that  of  the  dermoid  cyst,  and  the  cavity  looselv  plugged  with 
boracic  lint.  Under  this  skilful  handling  by  the  surgeon  the  patient 
rapidly  improved,  although  discharge  remained  and  required  daily 
irrigation.  The  patient  held  her  own,  wintering  at  San  Remo  for 
two  or  three  years,  and  finally  died  from  drain  poisoning  at  some 
mountain  resort  in  the  summer  of  1891. 

In  this  case,  in  the  absence  of  post-mortem  examination,  we 
may  infer  that  the  malady  started  in  the  upper  mediastinum  by 
extension  from  a  remnant  of  dermal  tissue  involuted  and 
detached,  and  for  a  time  embedded  in  the  tissues.  The  first 
effect  of  its  active  growth  and  intrusion  into  the  pleural  cavity 
was  to  set  up  pleurisy  and  empyema,  the  dermoid  growth 
gradually  extending  to  occupy  much  of  the  cavity.  The 
empyema,  with  which  it  was  complicated,  then  perforated  the 
pulmonary  pleura  and  thus  permitted  some  of  the  hairs  from 
the  growth  to  escape  through  the  lungs. 

A  case  of  "  dermoid  growth  of  the  lung  "  closely  resembling 
that  above  described  was  brought  before  the  Pathological 
Society  by  Dr.  Cyril  Ogle,"  in  which  the  cyst  was  embedded  in 
the  lower  lobe  of  the  left  lung,  occupying  a  cavity  of  about 
four  inches  in  diameter,  and  communicating  freely  with  the 
left  bronchus.  The  contents  were  of  the  usual  character, 
including  five  or  six  stalked,  tongue-like  processes  with  short 
hairs  growing  upon  their  surfaces.  The  stalks  were  united  and 
appeared  to  grow  from  the  wall  of  the  cyst,  but  the  united  stem 
could  be  traced  upwards  into  the  mediastinum  at  the  level  of 
the  left  innominate  vein.  Embedded  in  the  common  stem  or 
core  a  large  tooth  was  found,  and  this  fact  places  the  case 
amongst  those  of  teratomata.  The  specimen  was  taken  from  a 
man,  aged  twenty-eight,  who  had  died  of  hjemoptysis. 

Although  it  may  be  regarded  as  in  the  highest  degree 
probable  that  some  intrathoracic  dermoid  growths  have  their 
origin  in  "  the  inclusions  of  portions  of  the  primitive  epiblast 
during  the  closure  of  embryonic  clefts"  (Shattock^"),  it  is 


384  DISEASES   OF   THE   LUNGS   AND   PLEURA 

likely  that  a  further  and  more  complete  examination  of  such 
cases  as  that  of  Mrs.  W.,  above  related,  may  prove  that  the 
majority  of  them  are  really  teratomata,  abortive  embryos, 
whose  origin  is  explained  on  the  theory  of  embryo-genesis  put 
forward  by  Mr.  Shattock.^*  The  structural  resemblances 
between  the  cyst  described  by  Dr.  Cyril  Ogle  and  the  one 
which  we  have  above  related  are  great.  It  was  only  on  close 
post-mortem  examination  in  Dr.  Ogle's  case  of  the  stalk 
whence  the  fleshy,  hair-covered  processes  projected  that  a 
tooth  was  found.  In  our  case  the  patient  died  of  another 
malady,  no  autopsy  was  made,  and  the  only  structures 
examined  were  some  of  the  fleshy  processes  removed  by 
Sir  Rickman  Godlee. 


REFERENCES. 

'  Tumours,  Innocent  and  Malignant,  by  Sir  John  Bland-Sutton,  LL.D., 
F.R.C.S.,  sixth  edition,  p.  524.     London,  1917. 

^  {a)  "A  Case  of  Intrathoracic  Dermoid  Cyst,"  by  H.  Batty  Shaw, 
M.D.,  and  G.  E.  O.  WiUiams,  M.B.,  The  Lancet,  1905,  vol.  ii., 
p.  1325  (with  bibliography).  See  also 
(b)  "  Case  of  Mediastinal  Dermoid,"  by  G.  E.  O.  Williams  (intro- 
duced by  Batty  Shaw,  M.D.),  Transactions  of  the  Clinical  Society 
of  London,   1906,  vol.   xxxix.,   p.   210. 

^  The  following  papers  give  a  nearly  complete  record  of  the  cases 
published  up  to  the  year  1914.: 

[a]  "  Beitrage  zur  Genese.  Pathologie  und  Diagnose  der  Dermoid- 
cysten  und  Teratome  im  Mediastinum  anticum,"  von  Dr.  Bruno 
Dangschat,  Beitrage  zur  Klinischen  Chirurgie,  vol.  cxxx.,  1903, 
p.  692. 

{b)  "  tJber  Mediastinal-Dermoide,"  von  Dr.  W.  Pohl,  Deutsche 
Zeiischrift  fiir  Chirurgie,  vol.  cxxx.,   1914,  p.  481. 

*  "  Case  of  Suppurating  Dermoid  of  the  Mediastinum,"  by  Thomas  R. 
Mouat,  M.B.,  British  Medical  Journal,  1909,  vol.  i.,  p.  90. 

^  See  Sir  Rickman  Godlee's  paper  dealing  with  the  case — "  Dermoid 
Cyst  of  the  Right  Side  of  the  Chest  communicating  with  a  Bronchus,"  by 
Rickman  J.  Godlee,  M.S.,  Transactions  of  the  Royal  Medical  and 
Chirurgical  Society,  1889,  vol.  Ixxii.,  p.  317 — in  which  the  curious 
processes  excised  are  figured. 

*  "Dermoid  Growth  of  the  Lung,"  by  Cyril  Ogle,  M.D.,  Transactions 
of  the  Pathological  Society  of  London,   1897,  vol.  xlvii.,  p.   37. 

'  {a)  "  An  Acardiac  Acephalous  Ovarian  Embryoma,  with  Remarks  on 
the  Pathogenesis  of  the  so-called  Dermoid  Cyst  of  the  Ovary,"  by 
S.  G.  Shattock,  Transactions  of  the  Pathological  Society  of  London, 
1907,  vol.  Iviii.,  p.   273. 

[b)  Loc.   cit.,  p.   303. 


CHAPTER    XXV 

SYPHILITIC    DISEASE    OF    THE    BRONCHI    AND    LUNGS 

Bronchial  Syphilis. 

The  respiratory  organs  may  become  affected  in  the  secondary 
or  tertiary  periods  of  syphilis.  In  the  eruptions  of  secondary 
syphilis  the  bronchial  mucous  membrane  is  sometimes  involved. 
It  is  true  that  the  positive  evidence  of  macular  syphilis  of  the 
bronchial  tubes  is  incomplete,  and  not  confirmed  by  post- 
mortem observation;  but  very  decided  symptoms  of  bronchial 
catarrh  are  so  frequently  met  with  in  association  with  the 
secondary  cutaneous  rash  of  syphilis  and  the  corresponding 
throat  affections  that  it  is  impossible  to  escape  the  conviction 
that  a  specific  catarrh  of  the  respiratory  tract  is  present  in  such 
cases.  Moreover,  condylomata  may  occasionally  be  visible  in 
the  larynx.  The  catarrhal  symptoms  and  mottled  cutaneous 
eruptions  of  syphilis,  together  with  a  certain  degree  of  pyrexia, 
may  be  mistaken  for  those  of  measles. 

We  have  not  observed  asthma  in  association  with  the 
bronchial  eruption  in  syphilis. 

Syphilitic  ulceration  of  the  bronchial  tubes  is  of  rare 
occurrence  during  the  secondary  period  of  the  disease,  and  is 
only  occasionally  to  be  met  with  in  association  with  tertiary 
lesions.  When  a  main  bronchus  or  the  bifurcation  of  the 
trachea  is  the  seat  of  a  syphilitic  ulcer,  paroxysmal  cough  and 
dyspnoea,  with  scanty  expectoration  occasionally  streaked  with 
blood,  may  be  expected,  and  the  diagnosis  would  be  helped  by 
the  observation  of  other  phenomena  of  syphilis.  The  ulcer 
may  perforate  the  trachea  or  bronchus,  and  produce 
mediastinal  or  pulmonary  abscess;  or  a  branch  of  the  bronchial 
artery  may  be  opened  up,  leading  to  severe  or  fatal  haemor- 
rhage. But  the  tendency  of  the  syphilitic  ulcer  is,  after  deep 
erosion  of  the  tissues,  to  cicatrise,  causing  contraction  and 

385  25 


386  DISEASES   OF   THE  LUiSTGS   AND   PLEURA 

deformity  of  the  tubes  affected,  and  leading  later  to  bron- 
chiectasis and  fibrosis  of  the  lung.  We  have  already  alluded 
to  narrowing  of  the  bronchi  as  one  of  the  dreaded  conse- 
quences of  syphilis  (see  p.  205).  Syphilitic  ulceration  of  the 
smaller  tubes  is  of  occasional  occurrence,  and  may  extend  into 
the  lung,  producing  peribronchial  pneumonic  consolida- 
tions. 

The  clinical  recognition  of  bronchial  syphilis  rests  upon  (i) 
the  presence  of  symptoms  of  broncho-pulmonary  disease  which 
are  not  in  the  order  of  those  characteristic  of  simple  bronchitis 
or  phthisis;  (2)  the  history  of  the  patient  and  the  manifestation 
of  the  syphilitic  cachexia  in  other  directions;  (3)  the  rapid 
amendment,  provided  the  disease  be  not  too  far  advanced,  that 
ensues  upon  antisyphilitic  treatment. 

.    Pulmonary  Syphilis. 

Syphilitic  lesions  are,  however,  not  confined  to  the  bronchi, 
but   may   occur   in  the   lungs   themselves,   both   in   the   con- 
genital and    acquired    forms    of    the    disease.     In    the   days 
anterior  to  the  discovery  of  the  tubercle  bacillus  this  affection 
was  believed  to  be  of  common  occurrence ;  but  it  is  now  known 
that  many  of  the  supposed  cases  were  in  reality  tuberculous  in 
nature,  and  that  the  disease  is  of  some  rarity.    Sir  J.  Kingston 
Fowler,^  after  a  careful  inspection  of  the  museums  of  the 
London  hospitals  and  of  the  Royal  College  of  Surgeons,  was 
unable  to  find  more  than  "  twelve  specimens  which  are  believed 
to  illustrate  syphilitic  lesions  of  the  lungs,"  and  of  these  he 
excluded    two    as    very   doubtful    examples.     This    museum 
experience,  however,  would  only  in  a  measure  coincide  with 
the  clinical  experience  of  the  disease,  since  cases  recognised 
will  often  yield  to  appropriate  treatment.    On  referring  back 
to  clinical  notes  of  1,323  male  patients  suffering  from  various 
diseases,  none  of  them  hospital  cases,  and  of  the  age  of  twenty 
and  upwards,  seen  by  one  of  us,  53  cases  presented  a  definite 
history  of  syphilis;  out  of  this  number  there  were  5  cases  of 
lung   syphilis — viz.,   3   cases    of  gummatous   fibrosis,  one   of 
catarrh  associated  with  cutaneous  maculae,  and  one  of  acute 
pyrexial  lung-  syphilis,  described  later  in  the  text  (p.  389).     On 
the  other  hand,  out  of  the  same  series  of  cases  there  were  320 
cases  of  pulmonai-y  tuberculosis,  in  which  only  in  3,  or  less 
than  I  per  cent.,  was  a  syphilitic  history  apparent. 


PLATE  XXII 


Congenital  Syphilitic  Pneumonia. 


Tof  ace  p.  387. 


CONGENITAL  SYPHILITIC  PNEUMONIA 

The  illustration  shows  "  a  right  lung  affected  with  syphilitic 
pneumonia.  All  the  lobes  are  equally  affected,  the  lung  tissue 
presenting  a  white  hepatised  appearance.  There  is  no  evidence 
of  any  recent  inflammation  of  the  pleura,  nor  any  adhesion  of 
the  lobes  to  each  other.  The  surface  of  the  lung  is  rough  and 
nodular. 

"  Microscopical  examination  revealed  a  generalised  interstitial 
inflammation  with  marked  thickening  of  the  adventitial  coat  of 
the  arteries.  A  few  of  the  alveolar  spaces  have  expanded,  and 
contain  numerous  desquamated  cells." 

From  an  infant  who  only  lived  for  a  quarter  of  an  hour.  A 
bullous  eruption  was  present  on  its  body,  and  the  hands  and  feet 
were  partly  denuded  of  epithelium.  The  lungs  were  entirely 
solid,  and  the  liver  and  spleen  were  enlarged. 

(From  the  Museum  of  St.    Bartholomew's   Hospital. 
Natural  size.) 


PLATE    XXII 


'If  J  TVM    {y?t:^ft' 


haii  Ay 


ruj 


iiiJUOO 


b^b'jr 


SYPHILITIC  DISEASE  OF  THE  BRONCHI   AND  LUNGS     387 

Congenital  Syphilis.- — In  this  form  of  the  disease  gum- 
matous nodules  are  occasionally  met  with;  but  more  often  the 
lesion  is  found  to  take  on  a  more  diffused  form,  producing 
the  so-called  "  white  pneumonia,"  or  "  white  hepatisation,"  of 
Virchow,  as  seen  in  the  syphilitic  foetus  or  new-born  child.  A 
lung  affected  with  syphilitic  pneumonia  is  heavy  and  solid,  of 
greyish-white  colour,  and  smooth  on  section  (Plate  XXII.), 
thus  presenting  a  very  different  appearance  from  the  granular, 
friable  surface  seen  in  ordinary  pneumonia.  Microscopically, 
the  alveolar  walls  are  found  thickened  and  infiltrated,  showing 
diffuse  chronic  interstitial  inflammation.  The  adventitia  of  the 
arteries  is  thickened,  and  the  alveoli  are  filled  with  shed 
epithelium  and  round  cells,  often  in  a  state  of  fatty  degenera- 
tion.- With  proper  staining,  spirochaetes,  often  in  very  large 
numbers,  may  be  demonstrated  in  such  lungs. 

Congenital  syphilitic  lung  disease  in  infants  is  a  matter  more 
frequently  of  post-mortem  than  of  clinical  observation,  the 
cases  in  which  it  occurs  being  generally  fatal  within  a  very  few 
hours  of  birth;  hence  it  is  of  small  clinical  importance.  No 
doubt  congenital  syphilis  has  something  to  do  with  catarrhal 
and  even  tuberculous  lesions  which  develope  in  later  childhood 
and  adult  life,  but  the  measure  of  its  influence  in  such  affections 
cannot  be  definitely  traced. 

Acquired  Syphilis. — The  lung  is  attacked  by  this  form  of 
syphilis  generally  in  from  four  to  six  years  or  more  after  the 
primary  infection,  but  we  have  known  twelve  years  to  elapse 
before  its  manifestation.  The  diffused  form  of  the  disease, 
seen  in  the  foetus  and  in  new-born  children,  is  rarely,  if  ever, 
met  with,  gummata  or  their  results  being  the  common  manifes- 
tations. These  may  occur  in  any  part  of  the  lung,  this 
irregularity  of  site  being  a  distinctive  feature.  In  appearance 
they  resemble  gummata  in  other  parts,  and,  as  in  the  liver, 
present  at  first  a  rose-grey  appearance.  Unlike  the  tubercu- 
lous nodule,  which  is  non-vascular,  the  gumma  contains 
vessels,  and  its  nutrition  is  thus  for  a  time  assured.  Gradu- 
ally, however,  the  vessels  undergo  the  changes  known  as 
endarteritis  obliterans,  the  blood-supply  becomes  cut  off,  and 
the  fibro-cellular  elements,  of  which  the  gumma  is  composed, 
undergo  caseation.  In  this  way  are  produced  the  yellow 
caseous  masses,  surrounded  by  the  fibrous  capsule,  with  which 
we  are  more  familiar.    Softening  and  breaking  down  occasion- 


388  DISEASES   OF  THE  LUNGS   AND  PLEURA 

ally  ensue,  but  the  cavities  so  formed,  unlike  their  tuberculous 
counterparts,  are  rarely  large.  More  often  the  gummatous 
mass  becomes  converted  into  fibrous  tissue,  which,  radiating 
into  the  lung  around,  causes  puckering  and  scarring  of  the 
viscus. 

There  can  be  little  doubt  that  cases  occur,  perhaps  with 
greater  frequency  than  is  suspected,  in  which  syphilis  of  the 
lung,  with  destructive  changes,  softening  and  excavation, 
associated  with  hectic  phenomena  and  wasting,  remains  un- 
treated, being  from  the  first  mistaken  for  tuberculous  disease. 
We  must  admit,  however,  that  the  majority  of  cases  believed 
by  older  writers  to  be  of  this  nature  were  in  reality  instances 
of  true  pulmonary  tuberculosis  occurring  in  syphilitic  subjects, 
while  a  few,  as  in  a  good  example  to  be  seen  in  the  Brompton 
Hospital  Museum,''  are  the  result  of  syphilitic  stenosis  of  the 
trachea  or  bronchi,  leading  (like  other  varieties  of  stenosis)  to 
the  formation  of  bronchiectatic  cavities  and  cirrhosis  of  the 
lung. 

Symptoms. — The  symptoms  of  pulmonary  syphilis  are  often 
obscure,  and  may  readily  be  confounded  with  those  of  ordinary 
inflammatory  conditions.   Gummatous  nodules  have  been  found 
in  those  who  during  life  presented  no  evidence  of  pulmonary 
disease.    The  symptoms  generally  present  are  those  of  chronic 
indurative   disease    of    the    lung    or   pleura  —  a   paroxysmal 
cough  with  difficult  expectoration,  of  obstinate  continuance 
uninfluenced  by  ordinary  remedies,  and  associated  with  but 
little  emaciation  and  no  pyrexia.     Pleuritic  pains  are  often 
present.     The  presence  of  such  symptoms  in  a  person  bearing 
the  marks  or  giving  a  history  of  syphilis  would  be  very  signi- 
ficant.     It    not    infrequently    happens,    however,    that    some 
peculiarity  or  incongruousness  in  the  symptoms  or  physical 
signs  leads  to  the  suspicion  of  a  syphilitic  taint,  the  surface 
marks  of  which  are  obscure,  and  the  history  of  which  is  at 
first   denied,   either  intentionally  or  through   ignorance.     In 
such  cases  a  Wassermann's  test  of  the  patient's  blood  may 
prove  of  value. 

Hcemoptysis  is  rare  in  the  early  stages,  and  when  it  occurs 
is  highly  suggestive  of  tuberculous  complication.  Cases, 
moreover,  do  occur,  such  as  one  to  be  presently  related,  in 
which  more  acute  symptoms  present  themselves,  including  a 
remittent  pyrexia,  and  such  cases  very  closely  resemble  tuber- 
culosis. 


SYPHILITIC  DISEASE  OF  THE  BRONCHI   AND  LUNGS     389 

Physical  Signs. — The  most  characteristic  physical  signs  are 
those  of  localised  pulmonary  induration — flattening,  dulness, 
or  a  sense  of  hardness  on  percussion,  with  enfeebled  breath- 
sound  of  blowing  quality,  with  few  or  no  moist  sounds.  Some 
bronchial  clicks,  or,  more  commonly,  a  superficial  crackle  of 
pleuritic  or  subpleural  source  may  be  heard.  Such  signs,  when 
presented  at  some  unusual  situation,  as  about  the  mammary  or 
inframammary  or  infraspinous  region,  are  very  suggestive.  It 
is  certain,  however,  that  in  some  cases  the  physical  signs  are 
not  localised  in  any  unusual  spot,  but  present  themselves  at  one 
or  other  apex,  and  under  these  circumstances  the  diagnosis 
from  chronic  tuberculosis  is  most  difficult.  The  presence  of 
considerable  one-sided  indurative  disease  of  the  lung,  of 
chronic  course  and  not  traceable  to  any  preceding  acute  attack, 
in  a  person  who  has  not  been  engaged  in  any  dusty  employ- 
ment, and  whose  sputum  contains  no  tubercle  bacilli,  should 
lead  to  a  suspicion  of  syphilis.  Having  arrived  thus  far,  a 
careful  inquiry  into  the  history,  an  examination  for  surface 
marks  of  the  disease,  and  a  Wassermann  test,  will  usually  clear 
up  the  case.  The  sputum  should  also  be  examined  for 
spirochaetes. 

Syphilitic  gummata,  as  we  have  said,  sometimes  soften  and 
produce  cavities,  which  are  small,  however,  and  often  too 
deeply  seated  for  recognition.  In  such  cases  severe 
haemoptysis  may  occur  from  the  rupture  of  a  large  vessel. 

Should  the  larynx  be  involved,  an  examination  will  disclose 
the  cleanly  cut  and  widely  destructive  ulceration  of  syphilis, 
or  in  later  and  less  active  stages  the  evidence  of  scarring  and 
deforming  cicatricial  changes. 

The  following  case  illustrates  the  great  similarity  which  may 
hold  between  syphilis  and  tuberculosis  : 

Mr.  P.,  aged  thirty-one,  engaged  in  commerce,  was  seen  by  one 
of  us  in  consultation  with  Dr.  Bulger,  of  Holloway,  on  August  4  and  5, 
1909.  He  admitted  of  no  illness  until  he  began  to  feel  unwell  and  to 
cough  in  the  beginning  of  January,  1909.  His  cough  continued,  he 
lost  flesh,  and  at  Easter  there  was  some  staining  of  the  expectora- 
tion. The  cough  became  more  severe  in  April,  and  since  the  middle 
of  June  he  had  been  in  bed  on  account  of  increasing  weakness  and 
a  daily  rise  of  temperature.  The  expectoration  was  examined  in  May 
with  a  negative  result  as  regards  tubercle  bacilli.  The  opsonic  index 
for  tubercle  was  found  to  be  062.  He  was  thin  and  hectic-looking ; 
his  teeth  and  gums  were  in  a  bad  condition,  and  pyorrhoea  alveolaris 
was  present. 


390  DISEASES   OF   THE  LUNGS   AND   PLEURA 

On  careful  examination  an  area  of  dulness  in  the  right  scapular  and 
interscapular  region  was  discovered,  extending  from  the  second  to 
the  sixth  rib.  Over  this  area  the  breath-sounds  were  feeble,  and 
some  scattered  moist  crepitations  were  audible.  These  signs,  with 
the  symptoms,  were  regarded  as  indicative  of  pulmonary  tuberculosis, 
although  it  was  recognised  that  the  duration  of  the  case,  the  com- 
parative paucity  of  the  physical  signs,  and  the  absence  of  tubercle 
bacilli,  confirmed  by  a  further  examination  of  the  sputum,  were 
anomalous  features.  The  question  was  duly  considered  whether  the 
trouble  was  a  sequel  of  influenza  or  a  consequence  of  oral  sepsis, 
removal  to  a  sanatorium  was  advised,  and  accordingly  Mr.  P.  was 
sent  to  the  Cotswold  Sanatorium,  under  the  care  of  Dr.  Kincaid,  to 
whom  we  are  indebted  for  the  further  history  of  the  case.  It  was 
on  August  13,  during  his  sojourn  there,  that  the  important  further 
fact  in  the  medical  history  was  elicited,  namely,  that  about  two  years 
previously  he  had  had  syphilis,  for  which  he  had  been  continuously 
under  treatment  for  twelve  months. 

On  admission  to  the  sanatorium  the  mouth  was  found  to  be  foul, 
and  as  it  had  been  suggested  as  possible  that  the  pulmonary  infection 
was  secondary  to  oral  sepsis,  and  as  on  further  examination  no 
tubercle  bacilli  were  found  in  the  sputum,  a  dental  surgeon  was  called 
in  and  the  mouth  cleared.  The  temperature  and  other  symptoms, 
however,  remained  (Fig.  37).  On  or  about  September  10  headache 
became  a  marked  symptom,  and  on  September  14  Dr.  Kincaid 
observed  a  definite  swelling  over  the  right  frontal  and  parietal  bones, 
having  the  characters  of  a  syphilitic  node.  The  temperature,  as  seen 
by  the  chart,  continued  to  rise  daily  to  100°  or  102°.  Iodide  of 
potassium,  which  had  been  commenced  on  first  eliciting  the  syphilitic 
history,  on  August  13,  but  could  only  be  tolerated  for  four  days,  was 
steadily  resumed  on  September  14.  The  physical  signs  and  symptoms 
now  began  rapidly  to  clear  up.  Mr.  P.'s  general  health  improved, 
his  temperature  became  normal,  and  continued  so  during  the  remain- 
ing eight  weeks  of  his  stay  at  the  sanatorium,  with  the  exception  of 
the  two  or  three  occasions  on  which  mercurial  injections  were  used, 
which  gave  rise  to  so  much  local  irritation  that  they  were  discontinued. 
He  left  the  sanatorium  in  the  middle  of  December,  1909,  having  gained 
3  stone  in  weight.  There  was  only  slight  dulness  remaining  at  the 
apex  of  the  lower  lobe  of  the  right  lung,  and  the  cranial  swellings 
had  completely  subsided. 

Dr.  Bulger  reported  in  October,  1910,  that  since  his  return  home 
he  had  continued  well,  and  had  resumed  his  work ;  and  again  in  1916 
and  at  the  end  of  August,  1918,  that  he  was  in  good  health. 

The  clinical  interest  of  this  case  is  obvious.  There  was  some 
difference  of  opinion  as  to  whether  it  was  one  of  a  chronic  septic 
condition,  in  which  the  lung  became  involved,  or  of  tuberculosis.  The 
specific  history,  carefully  concealed  from  his  family  attendant,  was, 
at  the  time  that  he  was  first  seen,  revealed  by  no  external  sign. 
Hence  the  hectic  features  of  the  case,  the  cough,  with  on  one  occasion 


SYPHILITIC   DISEASE   OF   THE   BRONCHI   AND   LUNGS      39 1 

blood-stained  sputum,  and  the  depressed  opsonic  index  of  resistance 
with  regard  to  tubercle,  were  strongly  in  favour  of  the  tuberculous 
view,  which  the  absence  of  tubercle  bacilli  from  the  sputum  on  several 
examinations  did  not  wholly  refute.     Nor  did  the  pyrexial  symptoms 


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OF  THE   Lung  described  in  the  Text. 

promptly  yield  when,  under  the  best  hygienic  circumstances,  it  was 
possible  to  clear  the  mouth,  until  the  manifestation  of  definite  external 
syphilitic  phenomena  imperatively  indicated  the  use  of  iodide  of 
potassium. 


392  DISEASES   OF   THE   LUNGS   AND   PLEURA 

Treatment. — In  the  treatment  of  pulmonary  syphilis  it  is  well 
to  commence  with  a  course  of  salvarsan,  provided  that  the 
heart  and  kidneys,  and  especially  the  liver,  appear  to  be  healthy. 
Neo-salvarsan  is  perhaps  the  best  preparation  to  use,  but  if 
it  cannot  be  obtained,  galyl  or  neo-arsenobillon  should  be 
substituted.  In  the  adult  06  to  09  gramme  of  neo-salvarsan 
may  be  injected  intravenously  with  full  antiseptic  precautions 
once  a  week  until  six  injections  have  been  given.  During  the 
course  mercury  and  iodide  should  also  be  prescribed.  If  the 
administration  of  mercury  by  the  mouth  causes  bowel  irrita- 
tion, 5  minims  of  sterilised  mercury  cream  (containing  i  grain 
of  metallic  mercury  in  5  minims)  may  be  injected  once  a  week 
into  the  muscles  of  the  buttock,  three  or  four  days  after  each  of 
the  salvarsan  injections;  or  the  drug"  may  be  administered  by 
inunction.  After  the  above  course  of  injections  the  salvarsan 
and  mercury  should  be  stopped,  but  the  iodide  continued. 
After  two  months,  if  the  Wassermann  reaction  is  still  positive, 
another  course  of  mercury  and  salvarsan  should  be  prescribed, 
and  the  iodide  afterwards  continued  with  intermitting  courses 
of  mercury,  the  Wassermann  reaction  being-  tested  from 
time  to  time.  In  some  cases  a  few  seasonal  courses  at  Aix- 
la-Chapelle  may  be  recommended,  and  in  all  the  general 
health  of  the  patient  must  be  well  looked  to  and  maintained. 

Pulmonary  Tuberculosis  in  Syphilitic  Subjects. 

More  common  than  true  pulmonary  syphilis  are  those  really 
hybrid  examples  of  tubercle  engrafted  upon  a  more  or  less 
strongly  marked  syphilitic  cachexia,  in  which  the  phenomena 
of  syphilis  are  manifested  with,  and  in  a  measure  modify  and 
control,  those  of  phthisis.  Cases  of  this  kind  present  certain 
peculiarities.  They  are  usually  of  the  caseous  pneumonic  type, 
being  one-sided,  with  rapidly  advancing  consolidation  and 
softening,  although  arrest  and  fibroid  changes  may  ultimately 
take  place.  Haemoptysis  is  an  early  and  an  urgent  symptom 
in  a  large  proportion  of  cases,  the  haemorrhage  being  severe 
and  recurrent.  The  evidences  of  lardaceous  change  in  other 
organs  present  themselves  at  a  relatively  early  period,  and 
with  greater  proportional  frequency  than  in  the  other  forms 
of  phthisis.  The  patient  may  present  other  marks  of  syphilis, 
such  as  cicatrices  upon  the  tongue  or  throat,  nodes,  cutaneous 
scars,  or  pigmentation.     His  build  and  conformation  of  chest 


SYPHILITIC   DISEASE  OF   THE   BRONCHI   AND   LUNGS      393 

are  often  not  those  of  ordinary  phthisis,  and  the  complexion 
has  the  earthy,  kistreless  pallor  of  the  syphilitic,  rather  than 
the  hectic  aspect  of  the  phthisical  cachexia.  In  other  cases 
the  patient  presents  the  aspect  typical  of  advanced  consump- 
tion, although  the  pulmonary  lesions  discoverable  are  but 
slig'ht;  in  such  instances  excessive  activity  in  anti-syphilitic 
treatment  may  have  prostrated  a  patient  of  tuberculous  con- 
stitution. 

The  treatment  requires  a  judicious  combination  of  anti- 
syphilitic  with  hygienic  measures,  which  may  prove  successful 
in  arresting  the  disease. 

REFERENCES. 
.    '  The  Diseases  of  the  Lungs,  by  James  Kingston  Fowler,  M.D.,   and 
Rickman  John  Godlee,  M.S.,  F.R.C.S.,  p.  429.     London,   1898. 

^  See— 

(i)  "Congenital  Syphilis  of  the  Lungs,"  by  Alfred  W.  Sikes,  M.D., 
F.R.C.S.,  The  Journal  of  Obstetrics  and  Gyncecology  of  the  British 
Emfire,  March,  1905,  vol.  vii.,  p.  194. 
(2)  "  A  Case  of  Infantile  Interstitial  Pneumonia,"  by  A.  W.  Sikes, 
M.D.,  Transactions  of  the  Obstetrical  Society  of  London^  1906, 
vol.  xlvii.,  p.  74. 

^  Specimen  No.  91.  See  Catalogue  of  the  Museum  of  the  Bromfton 
Hospital,  by  Percival  Horton-Smith  (Hartley),  M.D.,  F.R.C.P.,  and 
William  Thomas  Mullings,  M.D.     Adlard  and  Son,  1904. 


CHAPTER  XXVI 

STREPTOTRICHOSIS    (ACTINOMYCOSIS)    OF    THE    LUNG 

AND    PLEURA 

History  of  the  Disease. — Streptotrichosis  or  actinomycosis,  as 
it  is  still  termed  by  many  writers,  whether  attacking  the  lung 
or  other  organs,  is  no  new  disease;  but  until  comparatively 
recent  years  cases  of  it  would  seem  to  have  been  mistaken  for 
such  varying  maladies  as  cancer,  osteosarcoma  or  tubercle. 

The  parasite  was  apparently  first  observed  and  figured  by 
von  Langenbeck  of  Kiel  in  1845,  '^^  ^  case  of  caries  of  the 
spine,  though  the  observations  were  not  made  known  until 
many  years  later  by  Dr.  James  Israel.^  In  about  1855  it  was 
independently  observed  and  figured  by  the  late  Sir  Thomas 
Smith,^  though  here  again  the  drawings  were  not  published 
until  comparatively  recently.  Lebert,^  in  1857,  was  the  first 
actually  to  publish  a  description  and  illustration  of  the  parasite, 
the  organism  in  this  instance  being  obtained  from  a  case  of 
pulmonary  disease  supposed  to  be  cancerous,  which  terminated 
in  abscess  of  the  chest-wall.  It  was  not,  however,  until  1878 
that  IsraeP  first  definitely  drew  attention  to  the  disease  in 
the  human  subject.  In  the  following  year  Ponfick,*  showed 
the  parasite  to  be  closely  allied — he  believed  identical — with 
the  organism  described  by  Bollinger,^  in  1877,  as  the  cause 
of  the  disease  in  cattle.  From  its  radiate  appearance,  Hartz, 
a  colleague  of  Bollinger  in  the  Chair  of  Botany,  had  given  to 
this  latter  organism  the  name  "  actinomyces,"  or  "  ray  fungus."* 

The  Parasite. — Recent  research  has  shown  that  the  disease 
is  produced  not  by  a  single  parasite,  as  was  once  supposed,  but 
by  several  organisms  which  are  members  of  the  streptothrix 
group.  This  group  belongs  to  the  Hyphomycetes,  or  lower 
mould  fungi,  and  to  the  genus  Discomyces,  and  is  charac- 
terised by  the  following  features,  with  which  the  writings 
of  Mr.  Alexander  Foulerton^  have  made  us   familiar.     The 

394 


PLATE  XXIII. 


Fig.  2. 


Streptothrix  Disease  (Actinomycosis). 


To /ace  page  395 


STREPTOTHRIX  DISEASE  (ACTINOMYCOSIS) 

Fig.  I. — Specimen  showing  a  small  streptotrichial  mass  com- 
posed of  a  network  of  finely-branched  mycelium  ;  from  the  pus 
of   an   abscess   in   the  chest   wall   connected   with   an   empyema. 

(  X     lOIO.) 

Fig.  2. — Sputum  from  a  case  of  streptotrichosis  of  the  lung, 
showing  the  presence  of  scattered  branching  threads  of  a  variety 
of  Streptothrix.     (  x    loio.) 


(Drawings  by  Mr.  S.  A.  Sewell  from  preparations  by  Mr. 
Alexander  G.  R.  Foulerton,  F.R.C.S.,  stained  by  Gram's  method 
and  counterstained  with  eosin;) 


PLATE  XXIII 


STREPTOTRICHOSIS   OF   THE   LUNG   AND   PLEURA         395 

organisms  consist  essentially  of  filaments,  which  show  true 
branching-  (Plate  XXIII.),  and  are  thus  sharply  distinguished 
from  the  Schizomycetes,  or  fission  fungi,  as  represented  by 
ordinary  bacteria.  The  filaments  in  their  growth  tend  to 
cohere,  and  to  form  little  masses  presenting  a  felted  mesh- 
work  of  finely  branched  mycelium  (Plate  XXIII.,  Fig.  i).  They 
stain  well  by  Gram's  method,  and  in  their  early  stages  take  the 
stain  homogeneously  throughout  their  length.  Later  the 
protoplasm  within  the  sheath,  which  bounds  the  filament,  tends 
to  segment,  and  to  present  the  appearance  of  longer  or  shorter 
rods,  some  of  them  still  showing  lateral  branching.  In  the 
terminal  filaments  this  segmentation  is  sometimes  very 
marked,  and  rows  of  small  round  spores,  still  staining  by 
Gram's  method,  are  produced,  the  appearance  closely 
resembling  that  of  a  chain  of  streptococci.  Finally  the  sheath 
breaks  down,  and  the  spores  and  rod  segments  become  free. 

From  time  to  time,  when  growing  in  the  tissues,  the  mycelial 
mass  may  be  seen  to  be  surrounded  by  a  radiating  zone  of 
club-shaped  bodies,  which  do  not  stain  by  Gram's  method,  but 
may  be  counterstained  by  such  dyes  as  orange-rubin  or  picric 
acid  (Plate  XXIV.).  These  "  clubs  "  are  probably  not  organs 
of  fructification,  as  originally  believed,  but  degenerate  forms, 
produced  when  the  soil  in  which  the  parasite  grows  is  not 
especially  favourable.  In  man  their  presence  is  very  variable; 
in  cattle  they  are  more  common. 

In  the  discharges  from  actinomycotic  lesions  the  organisms 
are  often  visible  to  the  naked  eye  as  characteristic  scattered 
granules  of  greenish-yellow  colour  and  of  the  size  of  small 
pinheads.  They  may  be  detected  by  tilting  the  pus  along  the 
side  of  the  test-tube,  or  by  spreading  the  sputum  over  the 
surface  of  a  glass  dish;  but  if  not  specially  searched  for  they 
will  almost  certainly  be  overlooked.  The  granules  are  often 
very  numerous,  but  their  number  tends  to  vary  a  good  deal  in 
the  same  case  at  different  times.  Under  the  microscope  each 
little  grain  will  be  found  to  consist  of  a  meshwork  of  the 
finely  branched  Gram-staining  mycelium  already  described 
(Plate  XXIII.,  Fig.  i),  with  possibly  a  zone  of  clubs  surround- 
ing it  (Fig.  41,  p.  402),  but  this  is  not  common  in  man. 

In  a  certain  proportion  of  cases,  however,  the  organisms 
are  more  disseminated,  and  do  not  form  in  the  sputum 
the  characteristic  granular  masses  which  are  visible  to  the 


396  DISEASES   OF  THE  LUNGS  AND  PLEURA 

naked  eye.  In  such  cases  they  may  be  most  easily  detected  by 
staining  by  Gram's  method  and  counterstaining  with  eosin. 
The  branched  mycelial  threads  of  the  variety  of  streptothrix 
present  are  in  this  way  stained  blue,  and  stand  out  well  against 
the  pink  background  (Plate  XXIIL,  Fig.  2).  An  attempt  should 
then  be  made  by  cultivation  and  animal  experiment  to  complete 
the  identification  of  the  parasite,  though  the  task  may  be  by  no 
means  easy,  since  certain  varieties  of  streptothrix  grow  only 
with  great  difficulty  on  artificial  media.  We  may  add  that  some 
of  the  strains  prove  acid-fast,  staining  like  the  tubercle  bacillus. 

Distribution. — Members  of  the  streptothrix  group  have  been 
found  as  saprophytes  in  water,  in  air,  and  especially  in  soil,  and 
they  have  also  been  frequently  met  with  in  association  with 
certain  grasses  and  plants.  In  animals  they  have  been  found 
to  be  the  cause  of  disease  in  many  of  the  mammalia,  notably 
in  cattle;  and  in  man  several  species  have  been  isolated. 
Mr.  Foulerton^*  succeeded  in  differentiating  ten  varieties  of 
streptothrix  organisms  in  a  series  of  fifty-three  cases  investi- 
gated by  him.  If  the  tubercle  bacillus  be  classified  as  a 
streptothrix,  in  support  of  which  a  good  deal  of  evidence  may 
be  advanced  (p.  422),  the  pathogenic  interest  of  the  g'roup 
becomes  enormously  increased. 

Pathological  Anatomy. — As  the  result  of  the  introduction 
and  growth  of  one  or  other  species  of  streptothrix,  an  inflam- 
matory reaction  of  the  tissues  is  induced.  Around  the  fungus, 
and  about  any  centres  whither  its  offshoots  may  be  conveyed, 
the  structure  of  the  affected  organ  becomes  densely  infiltrated 
with  granulation  tissue,  in  which  epithelioid  cells,  and  some- 
times giant  cells,  may  be  seen.  This  is  at  first  freely  permeated 
with  new  vessels,  but  caseation,  degenerative  softening,  or 
suppuration  speedily  ensue,  coupled,  however,  with  some 
tendency  to  repair  as  shown  by  the  formation  of  fibrous  tissue. 
The  disease  in  these  respects  closely  resembles  tubercle,  but  it 
differs,  as  we  shall  see,  in  the  remarkable  disposition  shown  by 
it  to  transgress  the  bounds  of  the  organ  affected,  and  to  involve 
adjacent  parts.  The  malady  is  further  spread  by  the  trans- 
ference of  the  elements  of  the  fungus  through  the  blood- 
stream to  distant  localities,  where  secondary  foci  of  the  disease 
are  generated. 

Clinical  Features. — Streptotrichosis  primarily  affecting  the 
lung  or  pleura — and  it  is  sometimes  difficult  to  say  in  which  it 


STREPTOTRICHOSIS   OF   THE  LUNG  AND  PLEURA         397 

has  really  commenced — is  a  comparatively  rare  disease, 
though  no  doubt  cases  have  been  overlooked.  More  usually 
the  lung  is  affected  secondarily,  by  direct  extension  from  the 
liver  or  other  adjacent  organs. 

The  following  case,  in  which  the  disease  probably  originated 
in  the  pleura  and  spread  thence  to  the  lung,  will  serve  conveni- 
ently to  bring  together  the  more  important  clinical  features. 
It  is  interesting  to  note  that  this  was  apparently  the  first  case  in 
this  country  in  which  the  disease  was  recognised  during  life.* 

Case  I. — George  W.  H.,  a  thin,  well-featured  boy,  aged  nine,  with 
bright  eyes,  dark  hair,  long  eyelashes,  and  somewhat  hectic  appear- 
ance, was  admitted  into  the  Brompton  Hospital  on  October  8,  1888, 
under  the  care  of  Dr.  Douglas  Powell,  complaining  of  pain  of  a 
pleuritic  character  below  the  right  nipple. 

The  boy  was  of  healthy  parentage,  his  father,  mother,  and  three 
brothers  and  sisters  being  all  well,  but  there  were  cases  of  tubercu- 
losis amongst  the  uncles  and  aunts  on  both  sides.  His  father 
worked  at  a  dairy  as  milker  and  carrier.  The  boy  himself  had 
enjoyed  good  health  up  to  four  months  before  admission.  His  parents 
attributed  the  commencement  of  his  illness  to  a  blow  behind  the  ear 
received  at  school  early  in  June,  which  kept  him  at  home  for  a  week, 
with  headache  and  constipation.  He  returned  to  school,  however, 
until  the  holidays  commenced,  in  July,  when  he  was  sent  to  Brighton 
for  a  month,  but  returned  only  slightly  better  in  August.  For  the  six 
weeks  following  his  return  from  Brighton  the  boy  accompanied  his 
father  two  or  three  times  a  week  to  the  cowshed,  where  there  were 
about  150  cows,  remaining  there  two  or  three  hours  at  a  time.  The 
father  knew  of  no  illnesst  which  had  lately  affected  any  of  the  cows 
and  was  sure  that  none  had  died  during  the  past  year.  It  was  to- 
wards the  end  of  August,  six  weeks  before  admission,  that  he  com- 
plained of  languor,  disinclination  to  work  or  play,  and  some  pain 
and  tenderness  of  the  right  side  of  the  chest  when  touched  or  washed. 
A  little  later  he  developed  slight  headache,  with  some  hacking  cough, 
but  with  no  expectoration  or  haemoptysis.  Throughout  his  illness 
he  had  gradually  lost  flesh,  and  during  the  last  month  he  had  had 
night-sweatings  and  his  breathing  had  become  shorter. 

On  admission  the  right  side  of  the  chest  was  obviously  larger 
(i  inch  by  measurement)  than  the  left,  and  restricted  in  movement. 
About   the  mammary  region   the   intercostal   spaces   were  obliterated 

*  The  case  is  recorded  in  the  Transactions  of  the  Royal  Medical  and 
Chirurgical  Society.^ 

t  Professor   Crookshank   and  Mr.    Taylor  visited  the   dairy  on   Novem- 
ber   17,    and   found   the   cows   looking    healthy,    and   were   assured   by   the 
owner  and  by  two  of  the  milkers  whom  as  well  as  the  boy's  father  they 
questioned,    that   there   had   been    no   cases    of    "wens"    or    "  clyers "    or 
other  manifestations  of  streptothrix  disease  on  the  farm. 


398  DISEASES   OF  THE  LUNGS   AND   PLEURA 

by  a  smooth  and  rather  hard  swelling  of  the  tissues,  having  its 
centre  in  the  fifth  space  in  the  nipple  line  (Fig.  38,  A).  The  swelling 
was  exceedingly  tender  and  slightly  oedematous,  but  at  this  time  no 
distinct  fluctuation  could  be  felt,  nor  was  there  any  blush  of  redness 
on  the  surface.  On  sitting  the  boy  up,  the  head  was  observed  to 
be  inclined  to  the  affected  side,  and  the  scapular  angle  correspond- 
ingly tilted  inwards,  the  spine  being  slightly  curved  in  the  dorso- 
cervical  region,  with  concavity  to  the  right.  In  the  posterior  axillary 
line  a  second  larger  swelling  was  observed,  corresponding  with  the 
seventh,  eighth,  and  ninth  ribs  (Fig.  39,  B).  This  swelling  was  also 
tender,  brawny  to  the  touch,  and  suggestive  of  the  early  stage  of  a 


Fig.  38. — Diagram  showing  the  Physical  Signs  in  the  Case  of 
Streptotrichosis  of  Lung  and  Pleura  described  in  the  Text. 

A,  Pointing  of  prominent  and  softened  tissues  below  the  nipple  (the  lateral 
bulging  and  shading  extending  beyond  the  confines  of  thorax  proper 
shows  infiltration  of  the  chest  wall);  C,  skodaic  resonance;  D,  systolic 
murmur. 

pointing  empyema.     The  heart's  apex-beat  was  half  an  inch  to  the 
left  of  the  nipple  line. 

The  percussion  note  on  the  right  side  was  resonant,  of  somewhat 
skodaic  quality,  to  the  second  place  in  front  (Fig.  38,  C) ;  below  that 
point,  dull,  the  dulness  being  complete  at  the  fourth  cartilage.  Pos- 
teriorly there  was  dulness  from  the  lower  third  of  the  scapula  to 
the  base.  It  was  observed,  however,  that  the  upper  line  of  dulness 
was  not  horizontal,  but  slanted  downwards  towards  the  spine,  so  as  to 
be  at  a  lower  level  there  than  in  the  mid-scapular  and  axillary  lines. 
In  the  subclavicular  and  superior  scapular  regions  the  respiratory 
murmur  was  weak  but  vesicular,  but  over  the  dull  area  generally  the 


STREPTOTRlCHOSIS   OF   THE  LUNG  AND  PLEURA         399 

breath-sounds  were  absent  and  the  vocal  fremitus  was  lost.  On  the 
left  side  the  resonance  and  respiration  were  good. 

A  short  systolic  murmur  was  audible  at  the  right  third  cartilage 
(Fig.  38,  D) ;  otherwise  the  heart-sounds  were  natural.  The  liver 
dulness  blended  with  that  of  the  thorax,  and  did  not  extend  below 
the  cartilages,  nor  could  the  margin  of  the  liver  be  felt.  The  spleen 
was  normal. 

From  the  hectic  temperature  and  symptoms  and  the  physical  signs 
above  related  the  case  was  regarded  as  one  of  empyema.  Two 
punctures  with  a  fine  needle,  however,  in  the  fourth  and  fifth  spaces 
in  the  anterior  axillary  line  produced  only  a  little  blood. 

October  15. — Whilst  under  chloroform  for  more  complete  explora- 


FiG.  39. — Diagram  showing  the  Physical  Signs  in  the  Case  of 
Streptotkichosis  of  Lung  and  Pleura  described  in  the  Text  : 
Posterior  View. 

At  B  infiltration  and  bulging  of  chest  wall  are  shown. 


tion,  but  before  any  puncture  was  made,  the  patient  expectorated 
about  half  a  dozen  sputa  of  bright  blood.  A  fine  trocar  was  intro- 
duced by  Mr.  (Sir  Rickman)  Godlee  at  the  centre  of  the  posterior 
bulging,  and  some  drops  of  blood  came  out  through  the  cannula, 
which  on  examination  contained  only  fibrin  and  blood-cells.  The 
temperature  from  this  time  onwards  is  shown  on  the  chart  (p.  400). 
The  patient  as  a  rule  slept  and  took  food  fairly  well,  and  was  very 
placid  and  cheerful,  being  free  from  pain  except  when  touched  or  on 
coughing.     The  cough  was  troublesome,  but  without  expectoration. 

By  the  end  of  the  month  he  had  notably  lost  flesh  since  admission, 
and  the  appearance  of  hectic  was  more  marked.  The  swellings  had 
become   more   prominent   and   were   distinctly   elastic;    and    extending 


400 


DISEASES   OF  THE   LUNGS   AND   PLEURA 


PLATE  XXIV. 


Fig.  1. 


Fig.  2. 

Strep  tot  hrix  Disease  (Actinomycosis). 


To  face  fage  401 


STREPTOTHRIX    DISEASE    (ACTINOMYCOSIS)    OF    THE 
LUNG  AND  PLEURA 

Fig.  I. — Specimen  from  pleura  under  low  power,     (i"  obj.) 
Fig.  2. — The  same  more  highly  magnified.     (J'  obj.) 

a.  Central  network  of  branching  mycelium. 

b.  Palisade  of  clubs. 

c.  Surrounding  dense  fibro-nucleated  tissue,  plenti- 

fully supplied  with  bloodvessels. 

(From  drawings  by  Dr.  Wynter ;  stained  by  Weigert's  modi- 
fication of  Gram's  method  and  orange  rubin.) 


PLATE  XXIV 


STREPTOTRICHOSIS   OF  THE  LUNG  AND  PLEURA        40I 

downwards  and  slightly  forwards  from  the  original  seat  of  the  pos- 
terior swelling  was  a  pyriform  bulging,  three  inches  in  length,  with 
the  larger  end  depending,  which  yielded  semi-fluctuation  over  its 
whole  area,  but  no  impulse  on  cough.  There  was  some  redness  over 
the  posterior  swelling.  The  physical  signs  remained  much  the  same. 
Two  glands,  slightly  enlarged  and  movable,  were  to  be  felt  in  the 
right  axilla,  and  on  this  side  of  the  neck  along  the  anterior  margin 
of  the  sterno-mastoid  some  slightly  enlarged  glands  were  also  per- 
ceived. On  the  opposite  side  the  glands  were  not  enlarged.  The 
systolic  murmur  at  D  was  distinct,  short,  and  rough. 

Except  for  slight  labial  herpes  on  admission  the  patient  had  no 
sores  on  the  face  or  mouth.  The  milk  molars  were  much  decayed, 
but  the  permanent  teeth  sound. 

At  this  time  it  was  thought  that  there  was  malignant  growth  in 
the  thorax,  but  the  idea  of  there  being  pus  in  the  pleura  was  not 
wholly  abandoned. 

On  November  i  the  upper  and  posterior  of  the  two  swellings  was 
thoroughly  explored  with  the  aspirator  by  Mr.  Godlee,  but  only  some 
soft  caseous  material  was  found  in  the  cannula.  An  incision  was 
made  into  the  swelling,  and  a  large  collection  of  similar  material  with 
some  fresh  blood  was  found  between  the  ribs  and  the  skin.  An  inch 
of  the  sixth  rib  above  the  incision  was  removed,  the  pleura  incised, 
and  the  opening  having  been  dilated  by  dressing  forceps,  the  finger 
was  passed  in,  and  entered  a  soft  collection  of  the  same  material  as 
had  been  found  outside.  No  limitation  of  the  mass  could  be  felt ; 
some  partially  clotted  brain-like  material  mixed  with  blood  escaped, 
but  there  was  no  actual  flow  of  fluid  matter.  The  bleeding  was  con- 
siderable. Strips  of  lint  soaked  in  sublimate  lotion — i  in  2,000 — were 
inserted  to  plug  the  wound,  and  a  dressing  of  carbolic  gauze  was 
applied.  A  little  blood  was  expectorated  towards  the  end  of  the 
operation. 

November  2. — The  patient  passed  a  fairly  good  night;  there  had 
been  no  haemorrhage,  and  he  was  comfortable.  Portions  of  the  crude 
material  removed  on  the  previous  day  were  examined  by  Mr.  Taylor. 
Fresh  sections  taken  from  the  brain-like  material  were  made  the  same 
evening  and  stained  with  alum-carmine.  The  structure  generally 
was  found  to  be  of  the  nature  of  granulation  tissue,  finely  fibrillated, 
giving  at  parts  a  sponge-like  appearance  and  containing  many  vessels. 
There  were  also  observed  several  deeply  stained  bodies  having  the 
recognisable  characters  of  actinomyces.  At  the  earliest  opportunity 
specimens  hardened  in  alcohol  were  stained  by  Gram's  method,  and 
the  fungus  was  demonstrated  in  its  entirety,  exhibiting  both  threads 
and  clubs,  the  latter,  however,  not  taking  the  stain  (Plate  XXIV.). 

A  purulent  discharge  escaped  from  the  wound,  which  was  treated 
with  iodoform  and  antiseptic  lotions. 

November  10. — It  was  found  that  the  lower  swelling  communicated 
with  the  upper,  and  it  subsequently  burst  externally  through  a  small 
opening    leading    to    a    sinus    which    communicated    with    the    upper 

26 


402 


DISEASES   OF  THE  LUNGS  AND  PLEURAE 


wound.  On  pressing  on  the  surrounding  tissues  thick  blood-stained 
pus  freely  escaped,  and  was  seen  to  contain  innumerable  minute  white 
granules  resembling  the  bodies  found  in  bovine  actinomycosis  (Fig.  41). 
Professor  Crookshank,  who  was  kind  enough  to  assist  us  in  the 
investigation  of  the  case,  collected  the  pus,  and  inoculated  a  number 
of  tubes  of  various  nutrient  media.  The  surface  of  the  wound  was 
also  covered  with  yellowish-white  granules,  glistening  and  not  readily 
removed.  When  scraped  off,  the  material  was  found  to  contain 
iodoform  from  the  dressings  and  abundant  ray  fungi. 

The  boy  remained  free  from  pain,  cheerful,  and  placid,  but  his 
emaciation  increased,  and  the  pulse  quickened  to  130,  although  the 
respirations  were  quiet.  There  was  no  enlargement  of  the  liver.  The 
upper  level  of  dulness  reached  the  second  rib,  and  the  level  did  not  alter 
with  position.  Some  rather  fine  crackles  were  heard  over  the  second 
and  third  ribs,  with  very  weak  breath-sound.     Posteriorly  the  dulness 


Fig.  41. — Streptotrichosis  of  Lung  and  Pleura.  Cover-Glass  Prep- 
aration FROM  THE  Pus,  UNSTAINED,  MOUNTED  IN  GLYCERINE,  X  350 
(about),    SHOWING   THE    RADIATING    ARRANGEMENT   OF   THE    CLUBS   AROUND 

THE  More  Confused  Mycelial  Centres. 


reached  to  the  middle  of  the  scapula,  above  which  level  the  breath- 
sounds,  although  weak,  were  fairly  good. 

On  injecting  carbolic  lotion  into  the  wound  the  patient  coughed 
and  expectorated  a  frothy  muco-purulent  sputum. 

November  16. — Under  chloroform  two  anterior  abscesses  were 
opened,  and  the  opening  below  the  original  incision  was  enlarged. 
Thick  yellowish  pus  with  characteristic  granules  escaped  freely ;  and 
there  was  considerable  haemorrhage,  causing  some  degree  of  collapse. 
A  little  of  the  mare  solid  material  was  removed  by  scraping.  Professor 
Crookshank  was  present  with  sterilised  tubes,  and  took  a  considerable 
quantity  of  pus  and  thick  material  for  inoculation  into  animals.  The 
whole  of  the  right  thorax  was  more  or  less  puffy,  and  along  the  ribs, 
both  above  and  below  the  front  incision,  were  several  points  of 
fluctuation. 

The  wounds  all  had  a  languid  appearance,  edges  purplish,  granula- 
tions pale  and  large;  a  thickish  pus  adhered  to  them  in  places,  on 


STREPTOTRICHOSIS   OF   THE  LUNG  AND  PLEURA        403 

which,  and  on  bare  granulations,  were  seen  minute  dirty  yellowish 
granules,  varying  much  in  size,  one  of  them  as  much  as  a  millimetre 
across.  These  were  readily  shown  by  microscopic  examination  to  be 
portions  of  fungus.  As  yet  no  growth  had  protruded  from  the  wounds. 
Many  granules  were  visible  on  the  dressings,  and  some  doubtful  spots 
were  seen  in  the  expectoration,  which  was  still  scanty. 

November  20. — On  this  date  the  fungus  was  found  in  the  sputum 
for  the  first  time.  No  tubercle  bacilli  had  at  any  time  been  detected.  The 
urine,  of  specific  gravity  1028,  acid,  gave  a  decided  indican  reaction, 
and  rapidly  manifested  decomposition,  but  contained  neither  albumin 
nor  sugar. 

With  some  variations  from  day  to  day,  the  boy  gradually  lost 
ground,  becoming  more  emaciated  and  pale. 

December  18. — Several  swellings  had  appeared  upon  the  back,  all 
of  which  fluctuated,  but  as  they  were  not  painful,  they  were  not 
incised.  The  wounds  from  the  former  incisions  presented  a  thick, 
yellowish-white,  slightly  glistening  surface,  and  similar  masses  were 
fungating  through  other  places  in  which  abscesses  had  spontaneously 
given  way. 

Through  January  there  was  some  general  improvement  in  the 
patient,  and  the  activity  of  the  growths  seemed  somewhat  checked, 
but  after  several  partial  rallyings  and  relapses,  he  sank  exhausted 
on  February  26,  i88g. 

Abstract  from  the  Post-Mortem  Report^" — Thorax. — A  large 
mass  of  soft  material  was  found  to  occupy  the  pleural  cavity  of  the 
right  side  from  about  the  level  of  the  second  rib  downwards.  It  was 
very  soft,  pultaceous,  and  canary-coloured,  much  resembling  coarse, 
badly-made  mortar,  and  appeared  to  consist  of  the  same  material 
in  varying  stages  of  degeneration.  Between  the  base  of  the  lung 
and  the  liver  there  was  a  large  amount  of  similar  material,  with  which 
the  diaphragm  appeared  to  have  become  incorporated.  In  the  upper 
part  of  the  pleura  there  were  some  recent  adhesions. 

Lungs. — Right  :  the  lower  anterior  part  of  the  lower  lobe  and  the 
middle  lobe  were  converted  into  tough  fibrous  material,  which  had 
an  irregular  interlobular  distribution,  the  bands  of  which  enclosed 
small  pinkish  areas  like  altered  lung  tissue.  Here  and  there  in  the 
midst  of  the  fibrous  growth  there  were  irregular,  canary-coloured 
masses  like  that  above  described.  The  upper  lobe  was  plentifully 
studded  with  grey  nodules,  the  size  of  a  hemp-seed,  some  slightly 
pigmented,  and  exactly  resembling  tuberculous  nodules.  Left  lung  : 
aerated  throughout,  but  containing  scattered  nodules,  of  the  size  of 
a  pea  to  a  small  Spanish  nut,  which,  on  section,  had  the  characteristic 
canary-coloured  appearance. 

Abdomen. — Between  the  liver  and  diaphragm  there  was  a  collec- 
tion of  pultaceous  matter  similar  to  that  described  above.  The 
liver  itself  appeared  healthy,  but  on  section  about  one  inch  below 
the  upper  surface  an  abscess  the  size  of  a  small  orange  was  dis- 
covered, having  a  fibrous  tissue  wall  about  half  an  inch  thick.     The 


404  DISEASES   OF  THE  LUNGS  AND  PLEURA 

contents  consisted  of  tenacious  yellow  pus,  which  had  a  trabeculated 
appearance. 

The  right  lateral  sides  of  the  dorsal  vertebrae  were  covered  over 
by  the  growth  and  superficially  eroded.  Some  of  the  ribs,  between 
which  the  growth  had  passed  to  reach  the  outside  of  the  chest,  were 
also  eroded. 

Nothing  worthy  of  note  was  found  in  any  other  of  the  organs. 

Remarks. — The  setiological  history  of  this  case  does  not  throw  any 
definite  light  upon  the  exact  mode  in  which  the  malady  originated. 
The  occupation,  however,  of  the  father,  and  the  fact  that  the  lad 
apparently  often  accompanied  him  in  his  visits  to  the  cowsheds, 
rendered  possible  an  infection  from  a  vegetable  source,  which  is  often 
observed  in  these  cases. 

Even  after  post-mortem  inspection  it  was  not  easy  to  decide 
exactly  where  the  disease  originated,  although  it  is  clear  that  it 
flourished  chiefly  in  the  lower  two-thirds  of  the  pleural  cavity,  in- 
filtrating the  chest  wall  and  fungating  through  the  cutaneous  surface, 
denuding  the-  adjacent  vertebree,  and  commencing  to  invade  both  the 
diaphragm  and  pericardium. 

The  lung  was  collapsed  backwards  and  upwards,  toughened  and 
fibroid,  containing  also  many  centres  of  the  parasitic  disease,  but 
there  was  not  sufficient  evidence  of  any  considerable  primary  fungus 
disease  of  the  lung  with  subsequent  cicatrisation.  On  the  contrary, 
the  post-mortem  evidence  rather  favoured  the  view  of  the  compressed 
lung  having  become  the  seat  of  a  secondary  actinomycosis ;  the  left 
lung,  otherwise  healthy,  also  presented  centres  of  a  similar  kind  in 
an  early  stage. 

On  the  whole,  it  would  seem  probable  that  the  organism,  having 
gained  entry  through  the  respiratory  tract,  had  been  conveyed 
through  the  lymphatics  to  the  pleural  surface,  and  there  germinated 
and  flourished  in  inflammatory  materials  derived  from  the  pleural 
layers  and  their  subjacent  tissues,  the  bulk  of  the  growth  being  in 
the  thoracic  wall. 

The  clinical  features  of  the  case,  both  as  regards  the  symptoms 
and  signs,  were  in  the  first  instance  those  of  empyema.  On  puncture, 
however,  no  pus  could  be  obtained,  and  on  further  exploration  the 
evacuation  of  semi-clotted  material,  resembling  a  mixture  of  fluidi- 
fied brain-substance  and  blood,  quite  unlike  anything  which  had  in 
our  experience  been  removed  from  cases  either  of  intrathoracic  growth 
or  empyema,  seemed  to  justify  the  removal  of  a  portion  of  the  rib 
for  more  thorough  exploration  of  the  pleura.  The  case  now  presented 
the  appearance  of  some  degenerating  growth,  but  certain  signs  which 
have  been  above  related — and  especially  the  somewhat  slanting  and 
shifting  upper  line  of  dulness  and  the  skodaic  resonance  below  the 
clavicle— led  us  still  to  retain  the  hope  that  there  might  be  some  fluid 
collected  behind  a  thick,  caseous  layer  in  the  pleura,  or  possibly  con- 
nected with  some  degenerated  growth  in  the  pleura,  such  as  we  had 
once  before  met  with  in  a  case  of  dermoid  tumour  of  the  lung.     At 


STREPTOTRICHOSIS   OF   THE  LUNG  AND  PLEURA        405 

the  end  of  the  exploration,  however,  we  returned  to  the  belief  that 
we  were  dealing  with  an  anomalous  degenerated  and  softened 
malignant  growth  of  extreme  vascularity.  It  was  only  on  careful 
examination  by  Mr.  Taylor  of  the  material  removed  that  a  diagnosis 
was  arrived  at. 

The  following'  case  also  possesses  features  of  sufficient 
interest  to  be  here  recorded  : 

Case  II. — Mrs.  C,  aged  forty-five,  five  years  married,  no  family  or 
pregnancies,  was  first  seen  by  Sir  R.  Douglas  Powell,  in  consultation 
with  her  friend  and  family  attendant,  Dr.  Waithman,  towards  the 
end  of  April,  1903,  on  account  of  a  severe  pain  of  a  neuralgic  charac- 
ter in  the  right  shoulder  and  radiating  therefrom.  Mrs.  C.  had 
suffered  from  epileptic  attacks,  for  which  she  had  taken  bromide, 
the  last  fit  having  been  about  February,  1903.  She  had  also  had 
some  slight  uterine  troubles ;  otherwise  she  had  never  been  ill  until 
an  attack  of  supposed  whooping-cough  in  190 1,  which  was  followed 
by  some  pleurisy,  with  cough  and  night-sweatings,  which  gave  rise 
to  the  suspicion  of  commencing  tuberculosis.  The  cough  was  not 
attended  by  any  expectoration.  She  spent  the  winter  of  that  year 
at  Nice. 

The  winter  of  1902  was  passed  in  Egypt,  going  by  dahabieh  up  to 
Luxor,  and  during  that  time  Mrs.  C.  suffered  greatly  from  the  pain 
in  the  shoulder,  which  was  regarded  as  a  rheumatic  neuritis  and 
treated  by  salicylates,  and  by  increasing  doses  of  morphia  given  sub- 
cutaneously.  During  her  stay  at  Luxor  it  was  stated  by  Dr.  Appleby, 
under  whose  care  she  then  was,  that  her  evening  temperature  was 
never  below  100°,  sometimes  102°,  and  that  she  had  heavy  night- 
sweatings.  The  above  treatment  was  continued  on  her  journey  home, 
via  Naples,  during  which  she  underwent  great  suffering.  The  history 
of  the  pleuritic  attack  and  the  irregular  pyrexial  and  hectic  manifesta- 
tions were  in  support  of  the  belief  that  her  illness  was  tuberculous. 

When  first  seen  by  Sir  Douglas  Powell,  in  April,  1903,  on  her  return 
from  Egypt,  some  impairment  of  the  percussion  note  was  observed 
below  and  over  the  right  clavicle,  and  the  breath-sounds  were  noted 
to  be  harsh  and  wavy,  and  a  few  rales  were  heard.  On  sitting  the 
patient  up  and  passing  the  hand  over  the  supraspinous  region  on  this 
side  attention  was  at  once  attracted  to  a  fulness,  and  on  deepening 
the  pressure,  considerable  tenderness  was  elicited;  a  sense  of  elastic 
tension  was  appreciable,  but  no  distinct  fluctuation.  The  fulness  was 
also  apparent  on  inspection,  compared  with  the  other  side.  An 
abscess  connected  either  with  caries  of  the  upper  dorsal  vertebrae, 
or  growth,  or  actinomycosis,  was  diagnosed,  and  as  the  pain  was 
very  severe,  rendering  nights  sleepless,  except  after  strong  doses  of 
morphia,  and  days  wellnigh  intolerable,  the  aid  of  Mr.  (Sir  Rickman) 
Godlee  was  sought.  He  made  an  incision  between  the  superior  angle 
of  the  scapula   and   the  spinal   column,   passing   deeply  through  the 


406  DISEASES   OF  THE  LUNGS   AND  PLEURA 

several  layers  of  muscles,  until  finally  some  purulent  matter  welled 
forth,  which  on  examination  revealed  the  characteristic  grains  of 
actinomycosis.  The  pleura  was  reached,  and  found  adherent,  there 
being  no  pleural  collection. 

There  was  no  obvious  connection  between  the  abscess  and  the  lung, 
but  the  fact  that  the  lung  was  involved  in  the  disease  was  inferred 
from  the  physical  signs.  No  expectoration  was  at  this  time  obtain- 
able for  examination,  and  only  later  were  the  characteristic  granules 
discovered  in  the  sputum.  The  pain  was  at  once  so  far  relieved  that 
no  further  morphia  was  necessary.  The  abscess  continued,  however, 
for  a  long  time  to  discharge  through  a  fistulous  tract.  After  recovery 
from  the  first  operation  the  patient  was  put  upon  iodide  of  potassium 
in  doses  of  30  grains  a  day,  afterwards  increased  to  60  grains. 

Mrs.  C.  went  to  Scarborough  in  July,  1903,  and  subsequently  to 
her  home  in  Yorkshire,  living  out  of  doors.  She  gained  weight  and 
improved  generally,  but  towards  the  end  of  September  Dr.  Fisher, 
of  Skipton,  reported  :  "  For  the  past  ten  days  Mrs.  C.  has  not  been 
quite  so  well,  suffering  more  pain  in  her  chest  and  tenderness  all 
over  the  side.  She  cannot  localise  it.  Five  or  six  days  ago  pleuritic 
friction  could  be  distinctly  heard  just  behind  the  shoulder-joint;  to-day 
it  is  almost  gone,  and  she  has  less  pain  and  discomfort.  Her  cough 
is  still  troublesome  at  nights,  but  there  is  no  expectoration.  Since 
September  gth  her  temperature,  normal  in  the  morning,  has  ranged 
from  99°  to  100°  in  the  evening.  Between  August  i  and  Septembei'  19 
she  has  gained  in  weight  from  11  stone  3  pounds  2  ounces  to  11  stone 
II  pounds  7  ounces.  She  takes  from  three  to  four  pints  of  milk  each 
day,  also  her  full  doses  of  the  iodide.  Last  week  she  had  two  or  three 
profuse  perspirations  at  night.  The  wound  in  the  back  is  still  open 
and  discharges  a  little.  She  is  out  in  the  garden  in  her  chair  each 
fine  da)'."  Dr.  Waithman  saw  her  about  this  time  and  agreed  with 
the  above  note,  and  after  consultation  with  Dr.  Fisher  and  Sir 
R.  Douglas  Powell,  it  was  decided  for  her  to  go  to  Torquay  for  the 
winter.  When  passing  through  town  in  October,  1903,  a  second  in- 
cision, opposite  the  infraspinous  portion  of  the  scapula,  was  found 
necessary  to  relieve  some  pent-up  pus,  and  a  third  operation  was 
required  in  February,  1905,  eighteen  months  later,  before  the  wounds 
finally  healed. 

In  the  later  periods  of  surgical  treatment,  the  details  of  which  were 
carried  out  With  Mr.  Godlee's  usual  care  and  resourcefulness,  and 
require  no  special  mention,  peroxide  of  hydrogen  lotion  was  syringed 
into  the  wounds,  and  subsequently  iodoform  emulsion,  but  on  no 
occasion  did  any  such  lotion  find  entry  to  the  lung.  The  purulent 
discharges  were  repeatedly  examined,  and  always  showed  the  char- 
acteristic granules  and  microscopic  appearances  of  streptotrichosis, 
including  the  club-shaped  bodies. 

The  sputum,  which  at  first  could  not  be  obtained,  was  found  on 
October  23,  1903,  to  present  the  following  characters  :  it  was  com- 
posed   of    viscid   mucoid   material,    with    streaks    of   muco-pus ;    and 


STREPTOTRICHOSIS   OF   THE  LUNG  AND   PLEURA        407 

contained  also  some  small  opaque  grains  of  a  yellowish  colour,  the 
largest  about  the  size  of  a  small  pin's  head.  Microscopically  examined 
the  granules  were  found  to  consist  of  a  felt-work  of  mycelium,  which 
retained  the  Gram  stain,  and  from  which  projected  some  more  refrac- 
tive bodies  (presumably  clubs).     No  tubercle  bacilli  were  present. 

The  iodide  of  potassium  was,  with  occasional  breaks,  continued 
for  the  two  years  of  treatment.  Hygienically  Mrs.  C.  was  treated  on 
fresh-air  lines,  mainly  between  Yorkshire  and  the  South  of  England. 
The  wounds  finally  healed  in  1906.  Her  lung  signs,  which  never  gave 
serious  trouble,  cleared  up,  and  her  weight  increased  from  10  stone  in 
June,  1903,  to  between  11  and  12  stone,  at  which  it  has  since  remained. 
Except  for  occasional  epileptic  seizures  she  has  since  continued  in 
good  health,  and  Dr.  Waithman  informs  us  that  she  is  well  at  the 
present  time,  June,  1919. 

Mrs.  C.  was  not  a  horsewoman,  and  beyond  visiting  the  home  farm, 
there  was  no  special  connection  with  straw  or  herbage. 

Chief  Features  of  the  Disease. — Since  the  occurrence  of  the 
first  of  the  two  cases  above  recorded,  not  a  few  instances  of 
primary  streptothrix  disease  (actinomycosis)  of  the  lung  or 
pleura  have  been  described,  and  the  malady  is  probably  more 
common  than  is  usually  supposed.  Some  years  ago 
Dr.  Samuel  West"  collected  thirty  from  the  literature,  three 
more  have  occurred  at  the  Brompton  Hospital,""  and  during 
the  years  1900-1912  Mr.  Foulerton^"  himself  observed  fourteen 
at  the  Middlesex  Hospital. 

The  disease  may  occur  at  any  age,  and,  as  with  strepto- 
trichosis  of  other  organs,  is  more  often  met  with  in  the  male 
than  in  the  female.  Both  lungs  may  be  affected,  but  the  left 
is  more  commonly  the  seat  of  the  disease  than  the  right,  and 
usually,  though  by  no  means  always,  the  lower  part  of  the  lung 
is  first  attacked.  The  infection  may,  however,  commence  at 
the  apex,  as  in  the  second  case  which  we  have  described,  and 
the  disease  then  closely  simulates  pulmonary  tuberculosis. 
This  occurred  also  in  one  of  the  Brompton  cases,"*  in  which 
the  physical  signs  at  the  right  apex  were  strongly  suggestive 
of  early  tuberculous  disease,  and  were  believed  to  be  of  that 
nature  until  streptothrix  granules  were  found  in  a  secondary 
abscess,  and  were  then  at  once  looked  for  and  discovered  in 
the  sputum.  At  the  autopsy  in  this  case  the  appearance  of  the 
lung,  showing  fibrosis,  most  marked  at  its  upper  portion,  with 
areas  of  softening  and  scattered  patches  of  broncho-pneu- 
monia," closely  resembled  that  seen  in  cases  of  pulmonary 
tuberculosis.    In  other  instances  the  areas  of  individual  disease 


4o8  DISEASES    OF   THE  LUNGS   AND   PLEURiE 

are  larger,  and  the  involvement  of  adjacent  lung  less  marked 
than  is  commonly  seen  in  tuberculosis^-  (Plate  XXV.). 

If  the  pleura  be  affected  an  empyema  generally  results,  in 
the  pus  from  which  the  parasite  is  found.  The  occurrence  of 
pultaceous  material  in  the  pleural  cavity  without  suppuration, 
as  in  the  case  above  related,  is  not  common. 

In  its  intimate  pathology,  as  we  have  seen,  streptotrichosis 
is  closely  allied  to  tubercle,  yet  in  one  important  feature  it 
shows  a  striking  difference,  namely,  its  disposition  to  invade 
beyond  the  borders  of  the  organ  first  attacked,  and  to  pass 
"  across  country,"  so  to  speak,  through  adjacent  tissues  to 
other  parts  and  other  organs.  In  this  way  the  lung  is  not 
infrequently  invaded  through  the  diaphragm  from  the  liver, 
and  in  this  way,  too,  arises  that  infiltration  of  the  chest  wall 
and  the  formation  of  those  secondary  abscesses  which  are  so 
often  seen  in  streptotrichosis  of  the  lung  and  pleura.  Sir 
Rickman  Godlee'^"  calls  attention  to  the  small  amount  of  pus 
generally  contained  in  the  abscesses,  and  their  "indefinite 
spongy  walls,  easily  breaking  down  before  the  finger  in  all 
directions,  and  bleeding  very  freely,"  features  which  he 
regards  as  characteristic. 

There  is  one  other  feature  of  the  complaint  to  which  we 
must  refer,  namely,  the  tendency  for  the  organisms  to  pass  into 
the  blood-stream,  and  to  set  up  infective  abscesses  in  distant 
parts,  such  as  the  brain,  liver,  and  kidney.  This  "pysemic 
form"  of  the  disease,  as  it  is  termed,  is  not  very  uncommon, 
and  the  same  disposition  has  been  observed  when  other  organs 
than  the  lung  are  primarily  attacked. 

Diagnosis.— Pulmonary  streptotrichosis  should  at  once  be 
suspected  if  in  a  patient  with  symptoms  of  chest  disease 
induration  or  suppuration  of  the  chest  wall  makes  its  appear- 
ance. The  finding  of  the  parasite  in  the  pus  or  sputum  will 
complete  the  diagnosis. 

It  should  be  a  rule  also  to  bear  the  possibility  of  strepto- 
trichosis in  mind  in  all  cases  which  suggest  pulmonary 
tuberculosis,  and  especially  if  the  signs  be  atypical  or  basal 
in  character,  but  in  which  repeated  examination  of  the  sputum 
has  failed  to  reveal  the  presence  of  tubercle  bacilH.  In  all 
such  cases  careful  search  should  be  made  for  streptothrix 


organisms. 


Treatment.  —  Pulmonary    streptotrichosis    in    the    human 


PLATE  XXV 


:iTAJS 


STREPTOTRICHOSIS  OF  LUNG 

The  drawing  showr  a  section  of  the  right  lung.  Near  the  base 
of  the  lower  lobe  a  large  white  mass  of  irregular  outline  is  seen, 
composed  of  casej-.ting  material  honeycombed  with  suppurating 
foci.  Similar  smaller  masses  are  seen  scattered  through  the 
lobe ;  some  were  also  f  ounc  in  the  middle  lobe,  but  none  in  the 
upper  lobe  or  in  the  left  lung.  Microscopical  examination  of  the 
purulent  material  from  the  lung  revealed  the  presence  of  a  Gram- 
staining  and  acid-fast  streptothrix,  which  grew  well  on  artificial 
media  and  was  pathogenic  to  guinea-pigs  and  rabbits.  It 
closely  resembled  the  organism  originally  described  by  Eppinger. 

From  a  porter  aged  sixty-seven,  who  died  after  an  acute  ill- 
ness of  five  weeks'  duration.  The  case  is  described  by  Dr.  J.  M. 
Bernstein  in  the  Proceedings  or  the  Royal  Society  of  Medicine, 
vol.  ii.  (Pathological  Section),  p.  271. 

(From  the  Museum  of  the  Royal  College  of  Surgeons. 
Natural  size.) 


PLATE  XXV 


Streptotrichosis  of  Lung. 


To  face  p-  408 


STREPTOTRICHOSIS    OF   THE   LUNG   AMD   PLEURA         409 

subject,  if  untreated,  tends  to  pass  rapidly  from  bad  to  worse. 
It  is  important,  therefore,  at  the  earliest  moment  to  commence 
treatment  with  considerable  doses  of  iodide  of  potassium,  the 
only  drug  which  has  so  far  been  known  to  exert  any  influence 
upon  the  disease.  The  administration  of  the  drug  should  be 
pressed,  twenty  to  forty  grains  being  given  three  times  a  day, 
and  sometimes  even  larger  doses  may  be  prescribed  with 
advantage."  In  many  cases  associated  suppuration  calls  for 
surgical  treatment,  and  ver}"  favourable  results  have  in  some 
instances  followed  this  combination  of  medicine  and  surgery. 
It  cannot  be  said,  however,  that  iodides  are  always  successful, 
for  the  drug  has  in  some  cases  seemed  to  produce  no  effect. 
This  may  possibly  be  due  to  the  special  variety  of  streptothrix 
concerned  in  the  disease,  but  probably  also  to  the  malady  not 
being  recognised  and  boldly  attacked  at  a  sufficiently  early 
stage.  These  measures  may  be  supplemented  by  vaccine 
therapy.  At  first  a  stock  vaccine  should  be  employed,  to  be 
replaced  later  by  an  autogenous  vaccine,  if  it  be  found  possible 
to  grow  the  streptothrix  discovered  in  the  patient.  Cases  of 
streptotrichosis  have  been  successfully  treated  on  these  lines, ^* 
but  we  have  known  of  others  in  which  no  apparent  benefit  has 
resulted.  In  many  cases,  all  attempts  at  cultivation  have  failed, 
so  that  the  preparation  of  an  autogenous  vaccine  has  been 
impossible. 

The  patient's  diet  should  be  nutritious  and  sustaining,  port- 
wine  or  brandy  being  freely  given  when  indicated,  with  such 
drugs  as  bark,  quinine,  or  other  tonics.  Special  symptoms 
must  be  treated  as  they  arise. 

REFERENCES. 

'■  "  Neue  Beobachtungen  auf  dem  Gebiete  der  Mykosen  des  Menschen," 
von  Dr.  James  Israel,  VircJiow's  Archiv,  1878,  voL  Ixxiv.,  pp.  15  and  50, 
Plate  IIL,  Fig.  9. 

^  "  A  Fading  Record  :  Early  Observations  on  the  Ray  Fungus  by  Mr. 
Thomas  Smith,  F.R.C.S.,"  by  A.  A.  Kanthack,  M.D.,  M.R.C.P.,  St.  Bar- 
tholomew's Hosfiial  Journal,   1896,  p.   50. 

^  Traite  d'Anatomie  PatJiologique  Getter  ale  et  Sfeciale,  par  le  Docteur 
H.  Lebert,  tome  i.,  p.  54.  Paris,  1857.  See  also  Lebert's  Atlas,  tome  i., 
Plate  n.,  Fig.  16. 

*  Die  Actinomycose  des  Menschen,  von  Dr.  E.  Ponfick.     Berlin,  1882. 

*  "  Ueber  eine  neue  Pilzkrankheit  beim  Rinde,"  von  O.  Bollinger  (in 
Miinchen),  Centralblatt  fiir  die  M  edicinischen  Wissenschaften,  1877, 
No.  27,  p.  481, 


410  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

*  For  a  full  bibliography  of  the  subject  up  to  1906,  see  the  article  on 
"Actinomycosis  (Streptotrichosis),"  by  Theodore  Dyke  Acland,  M.D., 
Allbutt  and  Rolleston's  System  of  Medicine,  vol.  ii.,  part  i.,  p.  324,  1906. 

'  [a]  "  Some  Observations  on  a  Series  of  Seventy-eight  Cases  of  Strepto- 
thrix  Infection,"  by  Alexander  G.  R.  Foulerton,  F.R.C.S.,  Proceed- 
ings of  the  Royal  Society  of  Medicine  (Surgical  Section),  1913, 
vol.  vi.,  p.   132. 

(b)  The  Streptotrichoses  and  Tuberculosis  (being  the  Milroy  Lectures 
for  1910),  by  Alexander  G.  R.  Foulerton,  F.R.C.S.     London,  1910. 

(c)  "  The  Pathology  of  Streptothrix  Infections,"  by  Alexander  G.  R. 
Foulerton,  F.R.C.S.,  Allbutt  and  Rolleston's  System  of  Medicine, 
part  ii.,  vol.  i.,  p.  302,   1906. 

{d)  "  On  the  GcMeral  Characteristics  and  Pathogenic  Action  of  the 
Genus  Streptothrix,"  by  Alexander  G.  R.  Foulerton  and  C.  Price 
Jones.  Transactions  of  the  Pathological  Society  of  London,  1902, 
vol.  liii.,  p.  56. 

*  "  On  a  Case  of  Actinomycosis  Hominis,"  by  R.  Douglas  Powell,  M.D., 
F.R.C.P.,  Rickman  J.  Godlee,  M.S.,  F.R.C.S.,  and  H.  H.  Taylor, 
F.R.C.S.,  with  an  appended  "  Report  on  the  Morphology  of  the  Fungus," 
by  Edgar  Crookshank,  M.B.  Transactions  of  the  Royal  Medical  and 
Chirurgical  Society,   1889,  vol.  Ixxii.,  p.   175. 

'  (a)    The    specimen    is    preserved    in    the    Museum    of    the    Brompton 
Hospital.     See  Catalogue  of  the  Museum  of  the  Bromfton  Hosfiial, 
by    Percival    Horton-Smith    (Hartley),    M.D.,    and   William   Thomas 
Mullings,   M.D.,   Specimen  No.  89.     London,   1904. 
{b)  Loc.  cit.     Specimen  No.  90. 

"  "  Case  of  Primary  Actinomycosis  of  the  Pleura  in  a  Child  of  Six, 
with  a  Table  and  Analysis  of  Recorded  Cases  of  Primary  Actinomycosis 
of  the  Lung  and  Pleura,"  by  Samuel  West,  M.D.  Transactions  of  the 
Pathological  Society  of  London,  1897,  vol.  xlviii.,  p.   17. 

"  (a)   "A   Series  of   Cases  of  Actinomycosis,"   by  Rickman   J.    Godlee, 
M.S.,  F.R.C.S.,  The  L.ancet,  1901,  vol.  i.,  p.  3. 
{b)   Loc.  cit.     Case  2. 

'"  "  A  Fatal  Case  of  Streptotrichosis  with  Primary  Lesion  in  the 
Lungs — the  Organism  Pathogenic  for  Animals,"  by  J.  M.  Bernstein. 
Proceedings  of  the  Royal  Society  of  Medicine,  1909,  vol.  ii.  (Pathological 
Section),  p.  271. 

'^  "  Some  Cases  of  Actinomycosis,  with  Especial  Reference  to  Treat- 
ment by  Potassium  Iodide,"  by  R.  B.  Wild,  M.D.  British  Medical 
Journal,  1910,  vol.  ii.,  p.  851. 

"  [a)  "  A  Case  of  Actinomycosis  (Streptotrichosis)  of  the  Lung  and  Liver 
Successfully  Treated  with  a  Vaccine,"  by  William  H.  Wynn,  M.D., 
British  Medical  Journal,  1908,  vol.  i.,  p.  554. 
{b)  "  A  Case  of  Actinomycosis  Treated  by  a  Vaccine,"  by  John  Collie, 

M.D.,  J. P.,  ibid.,   1913,  vol.   i.,  p.  991. 
(c)    "Vaccine   in    Mediastinal  Actinomycosis,"   by   W.    S.    Malcolm, 
M.D.,   ibid.,    1916,  vol.   ii.,  p.   488. 


CHAPTER  XXVII 

SPOROTRICHOSIS 

This  disease  was  first  described  by  Schenck^  in  1898  in  the 
case  of  a  man  aged  thirty-six,  attending  the  Johns  Hopkins 
Hospital,  Baltimore,  and  has  since  been  chiefly  studied  in 
France  by  de  Beiirmann^  and  his  pupils.  It  is  produced  by 
various  closely  allied  filamentous  spore-bearing  fungi  belong- 
ing, like  the  Streptothrix,  to  the  Hyphomycetes  or  lower  mould 
fungi,  but  to  the  genus  Sporotrichum.  The  varieties  usually 
met  with  are  the  Sporotrichum  Schencki  and  the  Sporotrichum 
Beurmanni,  which  are  possibly  identical,  but  others  are 
described. 

In  the  pus  and  tissues  the  parasites  are  found  chiefly  as 
short  oblong  forms  resembling  bacilli.  When  cultivated  these 
yield  a  delicate  septate  branched  mycelium  which  soon  shows 
spore  formation,  the  spores  being  arranged  in  clusters  around 
the  end  of  a  filament,  or  less  commonly  along  its  sides.  The 
organisms  stain  with  the  usual  dyes  and  grow  well  at  room 
temperature  on  Sabouraud's  glucose-peptone  gelatine,  which 
should  be  used  for  their  isolation. 

The  parasite  is  found  widely  disseminated  in  nature,  and 
has  been  detected  on  lettuces,  potatoes,  grain,  bark,  and  thorns, 
and  is  thus  easily  conveyed  to  man.  Infection  usually  occurs 
in  patients  with  lowered  vitality,  and  is  produced  through  an 
abrasion  of  the  skin,  but  in  the  pulmonary  cases  inhalation 
may  be  the  mode  of  entry  as  in  the  case  of  a  woman  who 
attributed  her  complaint  to  her  dusty  occupation  in  a  coffee 
mill. 

The  characteristic  lesion  manifests  itself  as  a  small  hard 
nodule  or  gumma  in  the  subcutaneous  tissue,  which  after  some 
enlargement  undergoes  central  softening  and  abscess-forma- 
tion, or  becomes  converted  into  an  ulcer.  The  ulcer  is  of 
chronic  type,  and  suggests  a  syphiUtic  or  tuberculous  origin, 

411 


412  DISEASES   OF   THE  LUNGS   AND   PLEURA 

The  lesions  affect  chiefly  the  limbs,  and  especially  the  hands 
and  arms,  but  the  disease  may  become  disseminated  and  affect 
the  face  as  well  as  the  trunk.-^  Sporotrichosis  is  not,  how- 
ever, confined  to  the  subcutaneous  tissues,  and  may  attack  the 
bones  and  joints,  the  muscles,  the  epididymis,  the  eye,  the 
mucous  membranes  of  the  mouth  and  larynx,  and  occasionally 
the  lung,  in  which  case  the  symptoms  usually  suggest  a 
chronic  pulmonary  tuberculosis. 

The  following  case  of  the  rare  pulmonary  variety  of  the 
disease,  which  recently  occurred  in  Paris,  has  been  recorded 
by  Drs.  Schulmann  and  Masson  :  ^ 

A  workman,  aged  thirty-six,  developed  in  191 1  an  eruption  on  the 
face,  neck,  and  chest,  soon  spreading  to  the  extremities.  The  erup- 
tion was  of  chronic  type,  suggesting  syphilis,  but  the  Wassermann 
test  was  negative.  The  gummata  enlarged,  and  in  pus  obtained 
from  one  which  had  softened  the  sporothrix  was  found.  The  patient 
was  treated  with  iodide  of  potassium  with  benefit,  though  recovery 
would  appear  to  have  been  slower  than  is  usually  the  case,  but  in 
January,  19 13,  it  is  stated  that  the  lesions  were  all  cicatrised  with 
the  exception  of  one  on  the  leg,  and  in  March,  1914,  that,  save  for  some 
conjunctivitis,  recovery  was  complete. 

The  patient  appears  to  have  remained  well  until  May,  1916,  when, 
during  service  in  a  munition  factory,  he  began  to  cough  and  expec- 
torate, to  lose  weight  and  to  become  febrile.  Pulmonary  tuberculosis 
was  diagnosed,  but  tubercle  bacilli  were  never  discovered  in  the  sputum. 
Some  improvement  followed  visits  to  Cannes  and  Mentone,  and  he 
was  able  for  a  short  time  to  resume  work,  but  in  November,  1917, 
it  became  necessary  to  discharge  him  from  military  service,  and  his 
symptoms  becoming  aggravated  he  was  in  May,  1918,  admitted  to 
hospital  at  Bicetre.  He  was  then  much  emaciated  and  his  appear- 
ance strongly  suggested  phthisis.  Examination  of  the  chest  showed 
extensive  loss  of  resonance  over  the  right  lung,  especially  marked 
over  the  centre  of  the  chest,  with  moist  sounds  at  each  apex.  X-rays 
revealed  diffused  shadowing  over  the  right  lung,  with  some  mottling, 
and  in  the  left  lung,  extending  from  the  heart  region  almost  to  the 
diaphragm,  the  well-defined  shadow  of  a  somewhat  deep-seated  oval 
tumour  was  visible.  No  tubercle  bacilli  could  be  found  in  the  sputum. 
The  history  of  the  former  cutaneous  lesions  now  raised  the  suspicion  of 
pulmonary  sporotrichosis,  and  the  diagnosis  was  effected  by  lung 
puncture  into  the  point  of  maximum  dulness  on  the  right  side  of 
the  chest;  the  drops  of  blood-stained  fluid  thus  removed  were  in- 
oculated upon  Sabouraud's  medium  and  the  Sporotrichum  Beurmanni 
recovered,  apparently  in  pure  culture. 

This  case  proves  that  pulmonary  signs  and  symptoms  re- 
sembling those  of  phthisis  may  be  produced  by  the  action  of 


SPOROTRICHOSIS  413 

the  sporothrix,  and  renders  it  probable  that  other  cases  in 
which  sporotrichosis  has  been  diagnosed  from  the  discovery 
of  the  parasite  in  the  sputum  may  have  been  true  examples  of 
this  disease.  It  must  be  remembered,  however,  that  the 
sporothrix  may  sometimes  occur  as  a  saprophyte  in  the 
pharynx,  and  thence  find  its  way  into  the  sputum,  so  that  its 
mere  presence  in  the  expectoration  is  not  in  itself  conclusive 
evidence  that  the  pulmonary  disease  is  of  this  nature. 

Diagnosis  and  Treatment. — The  possibility  of  pulmonary 
sporotrichosis  must  be  borne  in  mind,  especially  when,  in  addi- 
tion to  symptoms  of  chest  disease,  chronic  cutaneous  lesions, 
suggesting  a  tuberculous  or  syphilitic  nature,  are  present.  If 
the  Wassermann  test  be  negative,  the  pus  from  one  of  the 
softening  nodules  should  be  examined,  and  if  the  sporotrichum 
be  present  it  will  be  demonstrated  without  difficulty  by  cultiva- 
tion on  Sabouraud's  medium  at  room  temperature.  The 
diagnosis  may  be  confirmed  by  the  sporo-agglutination  re- 
action, on  the  lines  of  the  Widal  test  for  typhoid  fever,  an 
emulsion  of  the  spores  of  the  sporotrichum  being  used  instead 
of  the  bacillary  emulsion. 

If  left  undiagnosed,  the  disease,  which  is  of  a  very  chronic 
nature,  will  gradually  extend.  If  detected  early,  it  is  readily 
amenable  to  treatment,  yielding  quickly  to  the  administration 
of  iodide  of  potassium.  This  drug  should  be  given  internally 
and  also  applied  in  a  weak  solution  to  the  sores.  Dr.  de 
Beurmann  states  that  in  early  cases  and  in  otherwise  healthy 
subjects  cure  may  be  expected  in  four  to  eight  weeks. 

REFERENCES. 

*  "  On  Refractory  Subcutaneous  Abscesses  caused  by  a  Fungus  possibly 
related  to  the  Sporotrichia,"  by  B.  R.  Schenck,  M.D.,  Johns  Hofkins 
Hosfital  Bulletin,  December,   1898,  p.   286. 

^  [a]    "  On   Sporotrichosis,"   by   Lucien   de  Beurmann,   British   Medical 

Journal,  1912,  ii.,  p.  289. 
See  also — 

{b)  Les  Sforotrichoses,  par  de  Beurmann  et  Gougerot.     Paris,   1912. 
[c)   "  Les  Mycoses,"   par  de  Beurmann  et  Gougerot,   Nouveau   Traiti 
de   Medecine   et  de   Therafeutique,   par   A.    Gilbert   et   L.    Thoinot, 
vol.  iv.,  p.  383.     Paris,  1910. 

'  "  Etude  Clinique  d'un  Cas  de  Sporotrichose  Pulmonaire  (Presentation 
de  Malade),"  par  M.  M.  Ernest  Schulmann  et  A.  Masson,  Bulletins  et 
Memoires  de  la  Societe  Medicale  des  Hofitaux  de  Paris.  Paris,  1918,. 
p.  776. 


CHAPTER  XXVIII 

ASPERGILLOSIS 

In  the  preceding  chapters  we  have  discussed  the  results  of 
infection  of  the  lung  by  various  members  of  the  streptothrix 
and  sporothrix  groups,  parasitic  organisms  which  belong  to 
the  Hyphomycetes  or  lowest  order  of  mould  fungi.  We  have 
now  to  consider  the  malady  aspergillosis,  pseudo-tuberculose 
aspergillaire,  as  it  is  termed  by  French  writers,  in  which  the 
malady  is  caused  by  mould  fungi  somewhat  more  highly 
developed  and  belonging  to  the  family  Perisporacidae.^"  The 
term  "  pneumonomycosis,"  or  mould  disease,  sometimes  used, 
would  thus,  strictly  speaking,  include  all  three  diseases. 

More  than  one  member  of  the  genus  aspergillus  have  been 
found  in  the  sputum  and  in  the  lungs  in  various  diseases,  such 
as  pulmonary  tuberculosis,  bronchiectasis,  and  malignant 
disease.  The  presence  of  the  parasite  is  generally  noted  only 
towards  the  end  of  the  illness,  and  is  not  associated  with  any 
distinctive  symptoms.  Such  cases  of  secondary  aspergillosis, 
as  they  are  called,  consequently  possess  but  little  practical 
importance. 

Of  greater  interest  is  primary  aspergillosis,  which  is  usually 
produced  by  the  action  of  the  Aspergillus  fumigatus.  This 
variety  of  the  disease,  as  proved  by  Dr.  Renon,^  to  whose 
writings  we  are  much  indebted,  is  met  with  chiefly  among  the 
pigeon-feeders  and  hair-combers  in  Paris,  who  use  in  their 
work  grain  and  flour,  which  are  apt  to  be  contaminated  with 
the  spores  of  the  organism. 

Clinically  the  malady  may  present  various  forms.  It  rhay 
sometimes  resemble  an  acute  broncho-pneumonia,  and  termin- 
ate fatally  in  two  or  three  months,  the  lungs  after  death 
showing  numerous  patches  of  consolidation,  in  many  places 
broken  down  into  small  cavities.     Or,  again,  as  in  the  case 

414 


ASPERGILLOSIS  415 

reported  by  Drs.  Arkle  and  Hinds/  in  which  the  mycelium 
was  found  for  the  most  part  growing  "in  the  walls  of  the 
alveoli  and  in  the  substance  of  the  lung  itself,"  it  may  present 
the  signs  and  symptoms  of  a  rapidly  progressing  emphysema 
with  alarming  attacks  of  dyspnoea,  in  one  of  which  the  patient 
referred  to  died.  Two  cases  of  membranous  bronchitis  of  a 
very  chronic  type  have  also  been  traced  to  the  presence  of 
the  parasite  (Obici,*  Renon  and  Devillers"" ). 

Most  commonly,  however,  the  disease  presents  symptoms 
and  signs  which,  like  its  pathological  lesions,  strongly  re- 
semble those  of  pulmonary  tuberculosis.  It  may  thus  set  in 
with  cough  and  haemoptysis,  loss  of  weight,  impairment  of 
appetite,  and  increasing  debility.  Night-sweats  also  occur, 
and  fever  is  often  present,  the  temperature  reaching  100°  or 
101°.  The  sputum  is  muco-purulent.  On  examining  the 
patient,  slight  impairment  of  note  at  one  or  other  apex  may 
be  observed,  with  blowing  breathing.  Later  on  signs  of 
softening  and  cavity  formation  become  apparent,  as  the  con- 
solidations break  down.  The  course  taken  by  this  form  of 
the  disease  is  usually  a  chronic  one,  sometimes  extending  over 
several  years,  periods  of  quiescence  alternating  with  those  of 
activity.  Recovery  is  by  no  means  unknown,  arrest  being 
brought  about  by  a  form  of  fibrosis,  as  in  tuberculosis  of  the 
lungs. 

An  interesting  example  of  this  variety  of  the  disease  was 
recently  observed  by  Dr.  Holden,^  of  Denver,  Colorado, 
although  in  this  case  the  parasite  was  the  Aspergillus  nidulans, 
which  differs  morpholgically  from  the  Aspergillus  fumigatus 
in  the  branching  of  its  sterigmata.  The  patient  was  a  married 
lady,  aged  forty-seven.  Her  symptoms,  cough,  sputum,  loss 
of  weight,  clubbed  fingers,  and  hectic  fever,  suggested  phthisis, 
and  the  physical  .signs,  commencing  at  the  right  apex  and 
spreading  downwards  and  attacking  to  a  less  extent  the  left 
apex,  supported  this  diagnosis.  Tubercle  bacilli  were,  how- 
ever, never  found,  and  later  the  mycelium  of  the  Aspergillus 
nidulans  was  discovered  in  the  sputum.  She  died,  greatly 
emaciated,  after  an  illness  lasting  two  years.  An  interesting 
feature  of  the  case  was  the  enlargement  of  the  cervical  and 
axillary  glands,  which  at  one  time  led  to  a  suggestion  of 
Hodgkin's  disease.  On  section  one  of  the  glands  was  found 
to  show  no  evidence  of  glandular  structure,  but  to  be  con- 


4l6  DISEASES   OF   THE  LUNGS   AND   PLEURA 

verted  into  fibrous  tissue,  between  the  fiibres  of  which  the 
parasite  could  be  seen  in  large  numbers  on  microscopical 
examination. 

Diagnosis. — From  what  we  have  said  it  will  be  evident  that 
the  disease  cannot  be  diagnosed  during  hfe  by  any  cHnical 
examination.  Its  recognition  must  depend  upon  the  dis- 
covery of  the  parasite  in  the  sputum.  This  may  sometimes, 
as  in  a  case  recorded  by  Dr.  Solmersitz,"  be  detected  by  the 
naked  eye  in  the  form  of  little  masses,  the  size  of  a  pin's  head, 
resembling  the  grains  met  with  in  streptothrix  disease,  and, 
like  the  latter,  consisting  of  a  feltwork  of  branching  mycelium. 
But  more  commonly  it  is  first  discovered  in  specimens  of  the 
sputum  stained  with  such  simple  dyes  as  methylene  blue, 
thionin,  or  safranin,  when  it  appears  in  the  form  of  branching 
mycehal  threads,  with  spores  scattered  in  and  around.  The 
threads  have  somewhat  thicker  walls,  and  are  more  irregular 
in  shape  than  those  usually  met  with  in  streptothrix  infection, 
which  they  otherwise  closely  resemble.  The  aspergillus  may 
sometimes  also  be  demonstrated  in  unstained  sputum  which 
has  been  spread  upon  a  slide,  and  treated  with  a  solution  of 
20  per  cent,  potash. 

To  identify  the  parasite  thus  discovered,  cultures  from  the 
sputum,  expectorated  into  a  sterilised  vessel,  must  be  made. 
For  this  purpose  Sabouraud's  agar  medium  (containing  i  per 
cent,  peptone  and  4  per  cent,  crude  glucose),  on  which  the 
aspergillus  grows  well  at  room  temperature,  may  be  used,  or 
Raulin's  medium,^*  an  acid  liquid  containing  sugar,  which, 
while  favourable  to  the  growth  of  mould  fungi  at  37°  C,  is 
inimical  to  that  of  ordinary  bacteria.  In  this  medium,  if 
Aspergillus  fumigatus  be  present,  a  mycelial  growth  will  be 
noticed  on  the  second  day,  starting  from  the  particle  of  sputum 
introduced.  A  few  days  later  this  will  reach  the  surface  of 
the  liquid,  when  it  will  quickly  give  rise  to  a  whitish  velvety 
veil,  upon  which  after  a  few  hours  spores  will  develope,  when 
its  colour  will  change  to  a  bluish-green,  and  later  to  a 
brownish-black.  This  colour  of  the  culture  will  serve  to  dis- 
tinguish Aspergillus  fumigatus  from  other  members  of  the 
genus,  which  have  also  been  met  with  in  sputum.  To  com- 
plete the  identification  of  the  organism  intravenous  injections 
of  the  spores  must  be  made,  preferably  into  the  vein  of  a 
rabbit's  ear.     If  the  parasite  be  the  Aspergillus   fumigatus, 


ASPERGILLOSIS  417 

the  animal  will  succumb  in  six  to  eight  days  with  general 
dissemination  of  the  fungus. 

Should  the  patient  die,  the  parasite  thus  discovered  in  the 
expectoration  will  also  be  found  in  the  lung',  unless  the  case 
be  a  very  chronic  one,  scattered  through  the  foci  of  disease, 
sometimes  appearing  as  small  white  or  brownish  patches 
visible  to  the  naked  eye.  In  addition  to  the  mycelium,  spore- 
bearing  hyphae,  with  spores  still  attached,  may  also  be  dis- 
covered in  the  bronchi  and  alveoli. 

Treatment. — No  specific  drug  treatment  is  known,  and  the 
patient's  resistance  must  be  strengthened  by  abundance  of 
fresh  air  and  good  food.  Symptoms  must  be  met  as  they 
arise.  Cod-liver  oil  has  been  found  of  great  value,  and  arsenic 
and  iodide  of  potassium  should  be  tried,  since  they  have  been 
found  by  Renon  to  lengthen  the  duration  of  life  in  animals 
experimentally  inoculated  with  the  disease.  In  the  less  acute 
cases  much  may  be  hoped  from  such  measures  of  treatment, 
and  recovery  may  result. 

REFERENCES. 

'  [a]  Practical  Bacteriology^  Microbiology,  and  Serum  Therafy  (Medical 
and  Veterinary),  by  Dr.  A.  Besson.     Translated  by  H.  J.  Hutchens, 
D.S.O.,  etc.,  p.  694.     London,  1913. 
{b)  Loc.   cit.,  p.   38. 

^  (a)  Etude  sur  V As-pergillose  chez  les  Animaux  et  chez  V Homme,  par  le 
Docteur  Louis  Renon.  Paris,  1897. 
[b)  "  L'Aspergillose,  Maladie  Primitive,"  par  M.  le  Docteur  Louis 
Renon,  XIII'^  Congres  International  de  Medecine,  Section  de  Path- 
ologie  Interne.  Paris,  1900,  p.  312. 
(<r)  "  Bronchite  Membraneuse  Chronique  Aspergillaire  Primitive,"  par 
M.  Louis  Devillers  et  M.  Louis  Renon,  Bulletins  et  Memoir es  de  la 
Societe  Medicale  des  Ho-pitaux  de  Paris,  Decembre  i,  1899,  p.  902. 

'  "  A  Case  of  Pneumonomycosis,"  by  C.  J.  Arkle,  M.D.,  and  F.  Hinds, 
M.D.,  Transactions  of  the  Pathological  Society  of  London,  1896,  vol.  xlvii., 
p.  8. 

*  "  Ueber  die  Pathogenen  Eigenschaften  des  Aspergillus  Fumigatus," 
von  Dr.  Augusto  Obici  (zu  Bologna),  Beitrdge  zur  Pathologischen 
Anatomie  und  zur  Allgemeinen  Pathologie  {Ziegler),  1898,  Bd.  xxiii., 
p.   197. 

^  "  A  Case  of  Pulmonary  and  Glandular-Aspergillosis,"  by  G.  W. 
Holden,  M.D.,  Transactions  of  the  American  Climatological  and  Clinical 
Association,  vol.  xxxi.,  191 5,  p.  97. 

°  "  Beitrag  zur  Aspergillusmykose  der  Menschlichen  Lunge,"  von  Dr. 
F.  Solmersitz,  Deutsche  Medicinische  Wochenschrift,  1906,  No.  37,  p.  1490. 

27 


41 S  DISEASES   OF  THE  LUNGS   AND   PLEURA 

The  following  may  also  be  consulted  : — 

'^  "  A  Case  primarily  of  Tubercle,  in  which  a  Fungus  (Aspergillus)  grew 
in  the  Bronchi  and  Lung,  simulating  Actinomycosis,"  by  S.  W.  Wheaton, 
M.D.,  Transactions  of  the  Pathological  Society  of  London,  1890,  vol.  xli., 
P-  .34- 

*  "  Remarks  upon  a  Case  of  Aspergillar  Pneumonomycosis,"  by  Rupert 
Boyce,  M.B.,  Journal  of  Pathology  and  Bacteriology,  1893,  vol.  i.,  p.  163. 

'•*  "  A  Case  of  Pneumonomycosis  due  to  the  Aspergillus  Fumigatus,"  by 
Leonard  Pearson,  M.D.,  and  Mazyck  P.  Ravenel,  M.D.,  The  Philadelphia 
Medical  Magazine,  August,  1900. 

^^  PmiemonomyTiosis  As-pergillina,  von  Dr.   Fr.   Saxer.     Jena,    1900. 

''  "  Note  sur  une  Toxine  produite  par  I'Aspergillus  Fumigatus,"  par  le 
Dr.  E.  Bodin  et  L.  Gautier,  Annales  de  VInstitut  Pasteur,  1906,  tome  xx., 
p.  2og. 


CHAPTER  XXIX 

PULMONARY  TUBERCULOSIS 

etiology. 

Of  the  prevalence  of  phthisis  and  its  importance  to  the 
community  there  can  be  no  question.  The  statistics  of  the 
Registrar-General  for  England  and  Wales  show  that  for  the 
year  1918,  the  last  year  available,  46,077  persons  died  from 
it,  this  figure  representing  7-6  per  cent,  of  the  total  mor- 
tality from  all  causes.  It  should  be  further  noted  that  this 
mortality  from  phthisis  constituted  79  per  cent,  of  the  deaths 
from  all  forms  of  tuberculosis  (58,073),  thus  showing  the  pre- 
ponderant importance  of  the  pulmonary  form  of  the  disease. 

There  is  evidence  to  show  that  tuberculosis  has  existed 
amongst  the  people  of  very  ancient  civilisations.  In  a  report 
on  the  early  dynastic  burials  of  Egypt,  Professor  Elliott  Smith^ 
and  Dr.  Derry  describe  two  graves  as  containing  skeletons 
which  present  evidence  of  tuberculous  caries.  One  grave  con- 
tained a  man  and  a  woman,  the  man  with  extensive  caries  of 
the  three  lower  dorsal  vertebrae  causing  acute  kyphosis;  the 
woman  with  an  abscess  cavity  involving  the  bodies  of  the 
first  and  second  segments  of  the  sacrum,  with  extensive  erosion 
of  the  bones.  In  the  second  grave,  containing  two  men  and 
a  boy,  one  of  the  men  had  destructive  caries  of  the  tenth  and 
eleventh  vertebrae,  with  acute  curvature ;  in  the  boy,  the  lower 
three  dorsal  and  upper  two  lumbar  vertebras  were  affected. 
The  dates  of  these  early  Egyptian  burials  were  about  2,500  to 
1,500  B.C.  Professor  E,  Smith  and  the  late  Sir  A.  Ruffer^  have 
also  described  in  detail  an  example  of  Pott's  curvature  in  an 
Egyptian  mummy  of  the  twenty-first  dynasty,  about  1,000  B.C., 
with  spinal  curvature  and  psoas  abscess.  No  micrococci  or 
tubercle  bacilli  could  be  found.  These  authors  also  describe  a 
typical  example  of  hip  disease  in  a  child  which  was  probably 

419 


420  DISEASES   OF  THE  LUNGS   AND  PLEURZE       • 

tuberculous.  Another  similar  case  was  found  by  Dr.  Wood 
Jones/  in  which  the  lumbar  region  and  left  elbow-joint  were 
affected.  In  the  Nubian  collection  of  bones  in  the  museum 
of  the  Royal  College  of  Surgeons  there  are  two  specimens* 
presenting  all  the  characters  of  tuberculous  disease  of  the 
spine,  the  skeletons  being  of  dates  about  3,000  and  2,000  b.c. 
respectively.  Mr.  Shattock,  Pathological  Curator  to  the  Col- 
lege, who  has  been  kind  enough  to  give  us  the  above  informa- 
tion and  references,  states  that  in  none  of  the  specimens  has 
it  been  possible  to  demonstrate  the  tubercle  bacillus,  but  that 
the  lesions  in  question  can  only  be  attributed  to  tuberculous 
disease. 

Tuberculosis  of  the  lungs  has  been  known  from  very 
early  times.  Hippocrates  first  applied  to  it  the  term  "  phthisis," 
and  a  description  of  its  clinical  manifestations  may  be  found 
in  his  writings  and  in  those  of  Celsus,  Aretseus,  and  Galen. 
The  prevalence  of  the  disease  in  these  early  times  has  not  been 
recorded,  but  it  must  have  been  considerable. 

The  malady  may  be  defined  as  one  in  which  the  affected 
tissues  are  invaded  by  a  parasitic  organism,  the  tubercle 
bacillus,  under  the  influence  of  which  they  undergo  specific 
alterations,  become  inflamed,  and  perish.  It  is  a  disease  in 
which,  through  successive  periods  of  activity,  of  toxic  and 
suppurative  fever,  the  body  wastes  and  its  functions  languish. 
The  terms  "phthisis"  and  "consumption,"  so  long  appHed  to 
it,  are  thus  appropriate,  and  may  continue  to  be  used,  pro- 
vided they  are  restricted  to  those  forms  of  lung  disease  which 
are  produced  by  the  agency  of  the  tubercle  bacillus.  They 
are  clinical  terms,  as  cancer  is  a  clinical  term,  and  are  strictly 
applicable  to  the  lesions  and  clinical  phenomena  brought  about 
by  pulmonary  tuberculosis,  just  as  cancer  is  applicable  to  the 
lesions  and  phenomena  of  carcinomatous  or  sarcomatous 
growth,  and  in  this  restricted  sense  we  shall  employ  them 
synonymously  in  the  course  of  this  work. 

In  the  first  half  of  the  eighteenth  century  Silvius  recognised 
the  anatomical  relations  between  the  nodular  lesions  of 
phthisis  and  their  subsequent  destructive  changes,  but  it  was 
Bayle  who,  in  the  latter  part  of  that  century,  first  described  the 
tubercular  nodule,  and  under  that  name  recognised  its  con- 
stitutional character,  its  specific  caseous  changes,  and  its 
distribution  in  other  organs  than  the  lungs.     It  was  not,  how- 


ETIOLOGY   OF   PULMONARY  TUBERCULOSIS  42 1 

ever,  until  the  specific  cause  of  the  disease  was  demonstrated 
by  Koch  in  1882  that  its  aetiology  could  be  discussed  on  scien- 
tific lines.  Hence,  although  in  the  aetiology  of  pulmonary 
tuberculosis  we  have  to  consider  (i)  predisposing  causes — 
those  causes  or  conditions  which  bring'  about  a  state  of  recep- 
tivity, or,  in  other  words,  a  readiness  on  the  part  of  the  tissues 
to  receive  and  harbour  the  tubercle  bacillus — (2)  the  exciting 
cause,  the  Bacillus  tuberculosis  itself,  it  will  be  convenient  to 
take  the  second  heading"  of  the  subject  first. 

The  Bacillus  Tuberculosis. — The  specific  nature  of  tubercle, 
which  was  believed  in  by  Laennec  and  by  others  long  before 
his  time,  may  be  said  to  have  been  first  demonstrated  patho- 
logically by  Buhl  in  1857,  when  he  pointed  out  that  an  out- 
burst of  tuberculosis  was  almost  always  attributable  to  the 
previous  existence  of  caseous  matter  somewhere  in  the  body. 
Villemin^  advanced  the  question  a  step  farther  in  1865,  by 
showing"  that  caseous  matter  introduced  into  a  healthy  animal 
produced  tuberculosis,  and  that  therefore  the  tuberculosis 
virus  dwelt  in  caseated  products.  The  memorable  announce- 
ment of  Villemin's  discovery  by  Mr.  (Sir  John)  Simon  from 
the  Chair  of  the  Pathological  Society  of  London  was  followed 
by  numerous  experiments  in  this  country,  the  general  result 
being  that  Villemin's  conclusions  were  substantiated."  Fresh 
point  and  precision  were  given  to  the  conclusions  of  Villemin 
by  Koch's  discovery,  in  1882,  of  the  causal  agent  in  the  trans- 
mission of  tubercle,  the  Bacillus  tuberculosis,  which  is  present 
in  every  case  of  tubercle,  which,  when  inoculated  into  suscep- 
tible animals,  will  reproduce  the  disease,  and  which,  when 
freshly  cultivated  from  the  infected  tissues  of  such  secondary 
inoculation,  will  still,  when  reinoculated,  produce  the  same 
disease. 

In  considering  the  nature  and  modes  of  access  of  this 
organism,  it  must  in  the  first  place  be  admitted  that,  although 
for  an  indefinite  period  in  the  aetiology  of  human  and  probably 
in  that  of  bovine  tuberculosis  the  incidence  of  the  disease  has 
been  through  the  reception  of  bacillary  infection  derived  from 
human  or  bovine  sources,  yet  it  cannot  be  doubted  that  the 
original  or  root  source  of  the  infection  has  been  a  saprophytic 
fungus,  the  common  parent  of  all  varieties  of  tubercle  bacilU. 
Whether  this  fungus — probably  a  streptothrix — is  now  dis- 
coverable, and  may  still  be  a  source  of  fresh  infection  amongst 


422  DISEASES    OF   THE  LUNGS   AND   PLEURAE 

cattle  and,  through  them  or  independently,  of  other  beings,  is 
a  question  for  botanists  and  bacteriologists  to  solve  by  further 
research. 

The  main  facts  of  the  hfe-history  and  potentialities  of  the 
tubercle  bacillus  may  be  summarised  as  follows  : 

I.  The  bacillus,  whether  occurring  in  the  sputum,  the 
tissues,  or  derived  from  cultures,  appears  as  a  rule  in  the 
form  of  minute  rods  1-5  jj^  to  35  /x  in  length  (about  a  quarter 
to  half  the  diameter  of  a  red  blood-corpuscle)  and  03  jj.  in 
breadth.  They  may  be  straight,  but  often  they  are  some- 
what curved.  When  stained,  they  either  take  the  dye  uni- 
formly, or,  as  frequently  happens,  present  a  beaded  appear- 
ance, portions  of  the  bacilli  taking  the  colour  well,  while  the 
intervening  parts  remain  unstained.  Koch  himself  regarded 
these  unstained  portions  as  spores,  and  experiments  in 
regard  to  the  thermal  death-point  of  the  bacillus,  which  has 
been  shown  to  vary  between  65°  C.  and  90°  C,  support  this 
conclusion,  the  spores,  however,  resembling  those  of  a  mould 
rather  than  of  a  fission  fungus.^ 

The  researches  of  Metchnikoff,  Coppen  Jones,  and  others 
have,  however,  shown  that  sometimes  in  the  body-secretions, 
and  always  in  old  agar  cultures,  certain  of  the  bacilli  become 
much  elongated  and  filamentous;  and  show  true  branching. 
Further,  in  not  a  feAv  cases  the  terminal  ends  of  these  long 
fo"rms,  or  of  their  branches,  present  definite  club-formation. 
These  appearances  suggested  to  Metchnikoff  that  "the  bacillus, 
as  ordinarily  met  with,  is  not  the  end-stage,  but  only  a  stage  in 
the  developmental  cycle  of  a  filamentous  fungus."  This  view 
has  received  much  support  from  the  work  of  Babes  and 
Levaditi,  who  injected  tubercle  bacilli  into  the  subdural  space 
of  rabbits,  and  found  that  after  thirty  days  the  foci  presented 
appearances  closely  resembling  those  met  with  in  actinomy- 
cosis, a  central  mass  of  bacilH  and  filaments  being  observed, 
surrounded  by  a  radiating  zone  of  clubs.  Similar  results  have 
been  obtained  by  Friedrich  and  by  Schultze,  and  it  would  seem, 
therefore,  that  the  organism  should  be  regarded,  not  as  a 
simple  bacillus,  but  as  a  member  of  the  streptothrix  group 
belonging  to  the  Hyphomycetes  or  mould  fungi,  which  we 
have  considered  in  a  former  chapter.  With  this  view  the 
thermal  death-point  of  the  tubercle  bacillus,  to  which  we  have 
alluded,  is  in  agreement. 


ETIOLOGY   OF   PULMONARY  TUBERCULOSIS  423 

2.  The  tubercle  bacillus  differs  from  the  majority  of  patho- 
.^"enic  micro-organisms  in  not  staining  by  ordinary  methods. 
The  method  introduced  by  Ehrlich  is  that  usually  fol- 
lowed, and  depends  upon  the  fact  that,  though  the  tubercle 
bacillus  takes  up  stain  with  considerable  difficulty,  yet  the 
stain,  once  received,  is  held  with  tenacity.  Accordingly,  to 
stain  the  organism  strong  dyes  are  necessary;  while,  to  de- 
colourise the  surrounding  tissues  and  other  bacteria,  strong' 
acids  are  permissible.  To  denote  this  unusual  resistance  on 
the  part  of  the  bacillus  to  the  decolourising  action  of  strong 
acids,  the  term  "acid-fast"  (sauerfesi)  has  been  introduced. 
The  observations  of  Drs.  Bulloch  and  Macleod^  have  shown 
that  the  peculiar  staining  qualities  of  the  tubercle  bacillus  are 
dependent  upon  its  containing"  a  substance  having  all  the 
chemical  properties  of  wax,  and,  further,  that  its  acid-fastness 
is  due  to  the  alcoholic  ingredient  of  the  wax,  and  not  to  its 
fatty  acid  element.^*^' 

The  method  of  staining  as  generally  performed  at  the 
present  day  is  as  follows  :  The  material  to  be  examined — and 
in  the  case  of  sputum  one  of  the  small  white  points  of  caseous 
matter  should  if  possible  be  selected — is  spread  out  upon  a 
cover-glass,  dried,  and  then  stained  by  Ziehl-Neelsen  carbol- 
fuchsin  (concentrated  alcoholic  solution  of  fuchsin,  11  c.c. ; 
5  per  cent,  aqueous  solution  of  carbolic  acid,  100  c.c).  The 
staining  solution  must  be  warmed  until  steaming  occurs,  and 
should  be  allowed  to  act  for  five  minutes.  The  specimen  is 
next  washed  in  water,  then  placed  for  a  few  seconds  (five  to 
ten)  in  20  per  cent,  hydrochloric  acid.  When  no  further  colour 
is  discharged,  it  should  be  transferred  to  70  per  cent,  alcohol. 
After  a  few  seconds,  if  no  further  decolourisation  takes  place, 
it  is  washed  in  water,  counter-stained  in  Lofifler's  methylene 
blue  (ten  to  twenty  seconds),  washed  once  more  in  water, 
dried  between  blotting-paper,  and  finally  mounted  in  Canada 
balsam.  Stained  in  this  way,  the  tubercle  bacillus  acquires  a 
bright  pink  colour,  and  is  sharply  differentiated  from  the 
surrounding  blue  tissues. 

It  should  be  stated  at  once,  however,  that  this  method  of 
staining  is  not,  absolutely  distinctive.  The  smegma  bacillus 
and  the  bacillus  of  leprosy  have  long  been  known  as  acid- 
fast;  and  more  recently  numerous  other  organisms  have  been 
found  to  stain  in  exactly  the  same  manner  as  the  tubercle 


424  DISEASES   OF  THE  LUNGS   AND   PLEURA 

bacillus.  Amongst  these  we  may  mention  certain  varieties 
of  streptothrix :  the  Timothy-grass  bacilkis  and  the  bacillus, 
discovered  by  Moller  on  certain  grasses  having  a  wide  dis- 
tribution in  nature;  the  "mist  bacillus,"  found  in  the  dung 
of  various  animals;  and  the  butter-bacillus  of  Petri  and 
Rabinowitsch.  From  tubercle  the  smegma  bacillus  may  often  be 
distinguished  by  its  discolourisation  by  alcohol  subsequent  to 
its  treatment  with  acid,  in  accordance  with  the  routine  method 
of  staining  which  we  have  recommended,  as  well  as  by  certain 
morphological  differences.  Of  the  others  mentioned,  the 
leprosy  bacillus  is  met  with  but  very  rarely  in  this  country,  the 
acid-fast  streptothrices  would  be  distinguished  by  their  branch- 
ing, while  the  Timothy-grass  bacillus  and  its  allies  occur  only 
most  exceptionally  in  sputum  or  other  discharg'es  from  the 
human  subject.  Hence,  for  practical  purposes,  we  may  still 
rely  upon  staining  methods  in  clinical  diagnosis;  but  it  must 
not  be  forgotten  that,  if  scientific  accuracy  be  required,  the 
ultimate  proof  that  the  organism  in  question  is  the  tubercle 
bacillus  must  rest,  not  upon  morphology  and  staining  proper- 
ties, but  upon  cultivation  and  animal  experiment. 

3.  The  organism  can  be  grown,  although  slowly,  at  a 
temperature  of  37°  C.  to  38°  C.  (98°  F.  to  100°  F.)  on  blood- 
serum;  it  can  also  be  cultivated  in  broth,  upon  nutrient  agar, 
and  upon  potato,  provided  6  per  cent,  of  glycerine  has  been 
added.  In  milk  too  the  bacillus  grows  well  (Klein).  Another 
medium  more  recently  introduced  is  Dorset's  egg  medium,  and 
upon  this,  as  shown  by  Dr.  Stanley  Griffith,®  it  may  be  culti- 
vated with  comparative  ease  direct  from  sputum,  provided  an 
emulsion  of  the  sputum  be  first  treated  with  antiformin,  which 
destroys  the  saprophytic  organisms  gathered  during  the 
passage  of  the  expectoration  through  the  mouth.  Gelatine 
is  not  suited  to  the  cultivation  of  the  bacillus,  since,  under 
ordinary  conditions,  it  does  not  grow  at  a  temperature  below 
29°  C.  (84°  F.),  though  on  glycerine-potato-broth  growth  has 
been  observed  at  22°  C.  For  the  characters  of  the  growth 
on  various  media,  we  must  refer  our  readers  to  works  on 
bacteriology. 

4.  The  bacillus  is,  under  many  conditions,  of  very  tenacious 
vitality.  When  present  in  the  dung  of  cows  spread  upon 
pasture-land,  it  has  been  shown  by  Dr.  Stenhouse  Williams'" 
to  retain  its  viability  and  virulence  for  at  least  five  months, 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  425 

and  for  twelve  months  when  the  dung  is  stored  in  a  dark 
cellar.  In  decomposing  sputum  it  preserves  its  virulence  and 
capacity  for  development  for  six  weeks  or  longer,  and  for  six 
months  if  the  sputum  be  allowed  to  dry.  It  is  rapidly  killed, 
however,  in  from  a  few  minutes  to  some  hours,  according 
to  the  thickness  of  the  film,  by  exposure  to  direct  rays  of  the 
sun,  and  in  diffused  daylight  it  can  only  live  for  a  few  days. 
Exposure  to  ultra-violet  rays  is  even  more  speedily  fatal  to 
its  vitality. 

Again,  whilst  the  bacillus  will  resist  a  dry  heat  at  a  tempera- 
ture of  100°  C.  for  an  hour,  exposure  for  fifteen  minutes  to  a 
moist  heat  of  90°  C.  or  even  less  will  destroy  it.  If  suspended 
in  water  or  milk,  it  will  be  killed  by  raising  the  temperature 
to  boiling-point.  On  the  other  hand,  it  is  capable  of  resisting 
very  low  temperatures,  contact  with  liquid  air  (-186°  C.)  during 
a  period  of  forty-two  days  having  been  shown  by  Swithin- 
bank^^  to  have  little  or  no  effect  upon  its  vitality,  though  the 
virulence  of  the  culture  appeared  to  be  slightly  diminished. 

Certain  antiseptics  are  deadly  to  it.  It  is  killed  in  less  than 
a  minute  in  a  5  per  cent,  solution  of  carbolic  acid,  and 
formalin  and  other  antiseptics  are  also  fatal  to  its  vitality. 
Many  substances  can  inhibit  in  culture  the  growth  of  the 
organism,  but  no  antiseptic  has  as  yet  been  found  capable  of 
arresting  tuberculosis  when  administered  to  animals  already 
suffering  from  the  disease.  As  we  shall  have  occasion  to 
remark,  however,  when  dealing  with  treatment,  a  drug  which 
may  not  be  directly  fatal  to  the  organism  may  indirectly  so 
far  affect  it  as  to  render  it  an  easier  prey  to  the  vital  forces 
of  the  host. 

To  the  toxines,  whether  intra-  or  extra-cellular,  which  are 
formed  by  the  tubercle  bacillus  in  the  course  of  its  develop- 
ment or  multiplication,  many  of  the  symptoms  and  most  of 
the  pathological  features  of  the  disease  are  attributable;  but 
it  cannot  be  said  that  at  present  we  have  any  very  exact  know- 
ledge of  their  chemical  composition. 

Tuberculosis  is  often  met  with  in  certain  domesticated 
animals.  In  cows  and  pigs  it  is  common,  and  in  cattle  the 
disease  is  known  by  the  name  bovine  tuberculosis  or  Perlsucht. 
In  the  cat  and  dog  it  is  not  infrequent,  and  it  occurs,  though 
more  rarely,  in  the  horse,  sheep,  and  rabbit.  The  guinea-pig, 
when  inoculated,  proves  extremely  susceptible;  the  common 


426  DISEASES    OF   THE   LUNGS   AND   PLEURA 

fowl  and  other  birds  are  frequently  attacked.  The  bacilli  which 
cause  these  widespread  lesions  in  the  animal  kingdom  present 
certain  peculiarities  among  themselves,  and  may  be  differen- 
tiated into  three  types:  the  ai'ian,  bovine,  and  human.  The 
bacillus  of  avian  tuberculosis,  though  morphologically  re- 
sembling very  closely  the  human  bacillus,  differs  sharply  both 
from  the  bovine  and  human  types  in  cultural  characteristics, 
the  temperature  at  which  it  thrives  best,  as  well  as  its  in- 
fectivity  to  animals.  Man  is  but  little  susceptible  to  bacilli 
of  the  avian  type,  although  in  a  few  cases  such  organisms 
appear  to  have  been  isolated  from  tuberculous  lesions  in  the 
human  subject.  Bacilli  of  the  bovine  variety  are  somewhat 
shorter  and  plumper  than  those  of  the  human  type,  and  show 
a  much  greater  virulence  when  inoculated  into  the  ox,  the 
calf,  or  the  rabbit.  They  are  also  capable  of  infecting  the 
human  subject,  especially  in  early  life,  and  bacilli  having  all 
the  characteristics  of  the  bovine  type  are  not  infrequently 
found  in  the  tuberculous  lesions  of  childhood,  notably  in  the 
cervical  glands,  the  lesions  of  abdominal  tuberculosis,  and 
those  of  aHmentary  origin.  Infected  milk  and  meat  must, 
therefore,  he  regarded  as  a  source  of  danger,  though  the 
bovine  bacilli  which  they  contain  are  probably  less  virulent 
for  man  than  those  of  the  human  type,  which  are  responsible, 
as  we  shall  see,  for  nearly  all  cases  of  pulmonary  tubercu- 
losis. 

We  may  now  briefly  summarise  our  knowledge  respecting 
the  distribution  of  the  organism  in  the  lesions  of  phthisis,  a 
subject  investigated  by  numerous  observers,  and  notably  by 
our  colleague  Dr.  Percy  Kidd.^- 

1.  The  bacilli  are  to  be  found  in  the  sputa  at  some  period 
of  the  disease  in  all  cases  of  pulmonary  tuberculosis  (Plate 
XXVI.,  Fig.  i). 

2.  They  are  best  seen  in  lung  tissue  which  is  undergoing 
rapid  caseation,  and  may  generally,  therefore,  be  demonstrated 
with  ease,  and  often  in  large  numbers,  in  cases  of  acute  caseous 
pneumonia  or  phthisis  florida,  and  in  the  caseating  walls  of 
recent  cavities,  whether  large  or  small  (Plate  XXVI.,  Figs.  2 
and  3).  They  may  sometimes  also  be  found  in  abundance  in 
the  pus  from  empyemata  of  tuberculous  origin  (Plate  XXVII., 
Fig.  2). 

3.  In   other  tuberculous    consolidations    of  the    lung   the 


PLATE  XXVI 


TUBERCLE  BACILLI  IN  SPUTUM  AND  CAVITIES 

Fig.  I. — Sputum  from  a  case  of  pulmonary  tuberculosis  showing 
bacilli.     (  X  400.) 


Fig.  2. — Naked-eye  appearance  of  a  cover-glass  on  which 
secretion  from  a  pulmonary  cavity  was  spread  and  treated  by 
Ehrlich's  method  of  staining.  The  tubercle  bacilli  are  grouped 
together  so  thickl}'  as  to  be  visible  to  the  naked  eye  as  red  points. 

(Natural  size.     Preparation  and  drawing  by  Dr.  Percy  Kidd.) 


Fig.  3, — Section  through  wall  of  a  minute  pulmonary  cavity ; 
inner  margin  of  cavity  teeming  with  tubercle  bacilli  ;  none  else- 
where. 

fl.  Cavity. 

b.  Bacillary  margin. 

c.  Surrounding  caseous  tissue. 

(From  a  preparation  by  Dr.  Percy  Kidd.  x  75.  This  figure 
appears  also  in  the  Transactions  of  the  Royal  Medical  and  Chirurgical 
Society,  1885,  vol.  Ixviii.,  p.  114.) 


PLATE  XXVI. 


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Tubercle  Bacilli  in  Sputum  and  Cavities. 


To  face  />age  426 


ETIOLOGY   OF   PULMONARY   TUBERCULOSIS  427 

bacilli  are  often  sparse  and  rather  difficult  to  find.  Large  fields 
may  be  traversed  without  discovering-  them.  Their  presence, 
however,  cannot  be  doubted,  for  this  material,  when  inoculated, 
is  virulent  in  producing"  tuberculosis. 

4.  In  the  granulations  of  miliary  tuberculosis  in  the  human 
subject  bacilli  are  very  generally,  but  not  invariably,  to  be 
found,  and  often  only  in  small  numbers  (Plate  XXVII.,  Fig.  i). 

5.  The  bacilli  may  sometimes  be  found  in  the  blood  in 
advanced  cases  of  the  disease,  and  occasionally  even  in  the 
early  stages."  They  are  frequently  also  to  be  discovered  in 
the  stools,'^  whether  from  swallowed  sputum  or  intestinal 
lesions. 

Channels  of  Infection.— The  virus  of  tubercle  may  enter  the 
body  by  infection  of  the  ovum  (congenital  infection),  or 
through  the  skin  (inoculation),  the  food-passages  (ingestion), 
or  the  air-passages  (inhalation). 

1.  Congenital  Injection. — It  has  been  urged  by  Baumgarten 
that  phthisis  is  usually  acquired  by  direct  infection  of  the  ovum, 
the  bacillus  being*  conveyed  to  it  by  means  of  the  spermatozoa, 
or  more  commonly  through  the  blood  of  the  mother,  travers- 
ing the  placenta  and  thus  reaching  the  foetus.  Dr.  Cob- 
bett,^^"  in  his  work  on  the  causes  of  tuberculosis,  concludes 
that  congenital  infection  is  of  more  frequent  occurrence  than 
is  commonly  supposed. 

Foetal  tuberculosis  visible  to  the  naked  eye  is  rare,  whether 
in  men  or  animals,  and  experiment  has  shown  that  in  the  great 
majority  of  cases  tubercle  bacilli  are  absent  from  the  tissues- 
of  the  foetus,  though  more  extended  observations  in  regard 
to  stillborn  children  of  tuberculous  parents  are  required. 
The  new-born  child  rarely  reacts  positively  to  the  von  Pir- 
quet^''  tuberculin  test.  Further,  the  view  of  congenital  infec- 
tion presupposes  a  latent  period,  often  of  many  years,  before 
the  g'erm  takes  on  active  growth  and  symptoms  of  tubercu- 
losis arise.  The  theory  may  be  accepted,  as  Dr.  Sitzenfrey^^ 
has  shown,  as  an  explanation  of  certain  cases  of  phthisis 
occurring  in  early  childhood,  but  it  cannot  be  held  to  explain 
the  general  incidence  of  the  disease,  either  in  children  or  the 
adult. 

2.  Inoculation. — Only  very  rarely  can  phthisis  in  man  be 
attributed  to  this  cause.  Laennec  himself,  however,  is  said 
to  have  been  infected  in  this  manner,  and  similar  cases  are 


428  DISEASES   OF   THE   LUNGS   AND   PLEURJE 

recorded  from  time  to  time.^*    At  the  Brompton  Hospital  the 
following-  case  occurred : 

H.  M.,  aged  sixty-two,  for  twenty  years  pathological  assistant, 
whilst  staining  some  sputum  in  June,  igoo,  ran  a  pen  covered  with 
virulent  expectoration  into  the  flexor  tendon  sheath  of  the  middle 
finger  of  his  right  hand.  Tuberculous  tenosynovitis  resulted,  but 
the  trouble  was  arrested  by  the  timel)^  scraping  out  of  the  disease 
within  two  months  of  the  primary  infection.  ^^  He  then  returned  to 
his  work,  and  remained  well  until  the  spring  of  1904,  when  he  lost 
weight,  developed  cough  and  malaise,  and,  on  examining  his  sputum, 
found  tubercle  bacilli  therein.  His  chest  was  examined  by  one  of 
us,  and  slight  impairment  of  note  was  discovered  at  the  left  apex, 
but  no  adventitious  sounds.  He  was  admitted  into  hospital, 
and  later  went  to  the  Brompton  Hospital  Sanatorium  at  Frimley, 
in  Surrey.  After  some  months'  treatment  he  lost  his  cough,  the 
bacilli  disappeared  from  the  sputum,  and  he  was  discharged  with 
the  disease  arrested.  There  was  no  recurrence,  and  he  lived  com- 
fortably, on  a  pension,  until  he  developed  epithelioma  of  the  larynx, 
of  which  he  died  in  March,  1915,  at  the  age  of  seventy-seven. 

In  this  instance  it  would  seem  probable  that  at  the  time  of 
the  injury  a  small  focus  of  tuberculous  disease  formed  in  the 
lung,  and  that  later,  when  his  resistance  diminished,  it  took 
on  fresh  activity,  and  made  its  presence  apparent.  Such  cases 
are,  however,  quite  exceptional. 

3.  Inhalation  and  Ingestion. — Until  recently  it  was  always 
believed  that  inhalation  was  the  main  channel  of  infection, 
ingestion  playing  quite  a  subsidiary  role.  The  reasons  for  this 
belief  were  as  follows  : 

(a)  Numerous  observers,  Koch  himself  included,  showed 
that  pulmonary  tuberculosis  could  be  produced  in  animals  by 
the  inhalation  of  pure  cultures  of  tubercle  bacilli,  or  of  pulver- 
ised sputum  from  phthisical  patients.  Bruno  Heymann,^" 
further,  has  actually  demonstrated,  by  staining,  the  presence 
of  tubercle  bacilli  in  the  pulmonary  alveoli  of  g"uinea-pig"s 
killed  two  hours  after  an  experimental  inhalation.  This 
observation,  we  may  add,  derives  confirmation  from  the  work 
of  Ballin,-'  who,  experimenting-  with  the  spores  of  Aspergillus 
funiigatits,  proved  their  presence  microscopically  in  the  alveoli 
after  half  an  hour's  inhalation,  and  within  three  hours  they 
were  found  penetrating  the  alveolar  walls. 

(b)  The  view  received  support  also  from  the  fact  that 
enormous  numbers  of  bacilH  may  be  present  over  long  periods 


PLATE  XXVII 


TUBERCLE  BACILLI  IN  ACUTE  MILIARY  TUBERCU- 
LOSIS OF  LUNG,  AND  IN  PUS  FROM  A  TUBERCU- 
LOUS EMPYEMA. 

Fig.  I.— Acute  Miliary  Tuberculosis. — Lung  :  two  alveoli 
which  have  become  fused  together ;  alveoli  filled  with  large 
epithelioid  cells ;  tubercle  bacilli  in  large  numbers  between  the 
cells,  and  in  a  few  instances  within  the  cells  (a. a.). 

(From  a  preparation  by  Dr.  Percy  Kidd.  x  400.  This  plate 
appears  also  in  the  Transactions  of  the  Royal  Medical  and  Chinirgical 
Society,  1885,  vol.  Ixviii.,  p.  114.) 


Fig.   2. — Empyema    of-  Tuberculou.s    Origin.  — Pus    removed 
from  the  interior  of  the  pleura,  showing  abundance  of  bacilli. 

(From  a  preparation  by  Mr.  H.  H.  Taylor,  F.R.C.S.      X400.) 


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PLATE  XXVII. 


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Fig.  2. 

Tubercle  Bacilli  in  ac7de  Miliary  Tuberculosis  of  Lnvg 
and  in  pus  from  a  Tuberculous  Empyema. 


To  face  page  428 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  429 

of  time  in  the  sputum  of  a  consumptive  patient,  in  some  cases, 
as  computed  by  Professor  Cornet,  reaching  the  total  of 
7,200,000,000  a  day,  although  a  certain  proportion  of  them 
may  be  no  longer  living-.  It  seemed  most  reasonable  to 
believe  that  some  of  the  organisms  thus  so  profusely  ejected 
find  access  to  other  persons  by  means  of  the  respiratory  tract. 

(c)  Birch-Hirschfeld,  Schmorl,  and  others  demonstrated  that 
in  very  early  cases  the  primary  lesion  was  sometimes  found  in 
the  walls  of  the  fine  bronchi,  whence  it  spread  by  aspiration 
to  the  alveoli. 

The  above  facts  are  strongly  in  favour  of  the  view  that 
the  sputum  is  the  chief  source  of  danger  in  the  spread  of 
phthisis,  and  that  the  main  source  of  infection  is  by  inhalation. 
Both  Koch  and  Cornet  believed,  and  with  them  Kohhsch's" 
more  recent  experiments  are  in  accord,  that  the  mode  of  this 
infection  is  by  discharged  sputum  becoming  dried  and  mingled 
with  dust,  the  dust  thus  contaminated  being  wafted  into  the 
air  by  sweeping,  traffic  and  winds,  and  in  this  way  becoming 
inhaled.  Cornet  disbelievesr  in  moist  sputum  as  a  cause  of 
phthisis.  Professor  Fliigge,  of  Breslau,  and  his  pupils,  on  the 
other  hand,  maintain  that  the  infection  more  frequently  arises 
from  the  direct  inhalation  of  the  fine  droplets  of  infected 
sputum  which,  as  they  have  shown,  are  scattered  into  the  air 
by  the  consumptive  patient  in  loud  speaking,  and  more  so 
in  coughing  and  sneezing.  Seeing  that  such  droplets  may 
remain  suspended  in  the  air  as  long  as  five  or  six  hours, 
and  as  Dr.  M.  H.  Gordon^^  has  shown,  may  be  conveyed  to 
gTeat  distances,  in  one  case  as  far  as  71  feet  from  a  person 
speaking  vehemently,  ample  opportunity  is  given  for  their 
inhalation.  In  quiet  reading  or  speaking,  however,  no  such 
ejection  appeared  to  occur. 

It  has  recently  been  shown,  however,  by  Dr.  Chausse^*  that 
such  droplets,  which  consist  mostly  of  saliva,  contain  but  very 
few  tubercle  bacilli,  and  that  experimentally  it  is  difficult  to 
infect  guinea-pigs  when  exposed  to  such  droplets  by  allowing 
patients  to  cough  repeatedly  into  the  box  in  which  the  animals 
are  confined,  and  this  when  the  expectoration  of  the  patients 
was  proved  to  contain  an  average  of  60,000  tubercle  bacilli  in 
each  milHgramme  of  sputum.  Of  79  animals  so  exposed,  only 
one  acquired  tuberculosis.  On  the  other  hand,  it  proved  easy 
in  Dr.  Chausse's  hands  to  infect  guinea-pigs  by  the  inhalation 


430  DISEASES   OF   THE   LUNGS   AND   PLEURA 

of  dried  dust  derived  from  the  handkerchief  used  by  a  con- 
sumptive patient,  if  this,  after  partial  drying-  for  forty-eight 
hours,  was  shaken  in  the  box  containing"  the  animals.  Several 
handkerchiefs  from  different  patients  were  used,  and  in  all 
41  guinea-pigs  out  of  73  exposed  acquired  tuberculosis.  With- 
out denying  that  in  circumstances  of  great  intimacy,  as  when 
two  or  more  patients  occupy  the  same  bed,  infection  by 
droplets  may  become  operative,  the  experiments  quoted 
indicate  that  under  ordinary  circumstances  dust  infection, 
derived  often  from  the  patient's  clothes,  bed-linen  and  person, 
is  the  more  important  factor  in  the  spread  of  the  disease. 

That  inhalation  directly  into  the  air-passages,  whether  of 
sputum-infected  dust  or  droplets,  is  not  the  sole  or  even  the 
chief  method  of  infection  is,  however,  maintained  by  some 
observers  on  the  following  grounds  :  (a)  It  is  well  known 
that  if  suitable  animals,  such  as  guinea-pigs,  calves  or  pigs, 
be  fed  with  tuberculous  material,  lesions  of  the  intestinal  tract 
will  result,  with  secondary  involvement  of  the  mesenteric 
glands  and  later  of  other  organs  of  the  body,  among  which 
the  lungs  may  be  included.  Such  involvement  of  the  intes- 
tine often  occurs  in  phthisical  patients  who  swallow  their 
sputum,  and  primary  intestinal  tuberculosis  in  children  is  no 
doubt  also  due  to  the  ingestion  of  tuberculous  matter,  (b)  The 
work  of  numerous  observers  also  shows  that  under  certain 
circumstances,  without  producing  any  local  lesion,  the  bacilli 
may  pass  directly  through  the  wall  of  the  alimentary  tract, 
or,  as  indicated  by  Dr.  Walsham,-^  in  his  Weber-Parkes  Prize 
Essay,  through  the  tonsils  to  the  lymphatic  glands,  and  thence 
to  other  organs.  Thus,  in  a  case  observed  by  Dr.  Sidney 
Martin,  in  which  a  pig  was  fed  on  meat  from  a  tuberculous 
cow,  no  lesion  of  the  tonsil  resulted,  but  the  glands  below  the 
jaw  on  the  right  side  were  involved,  and  the  lungs  were  also 
infected;  the  other  organs  remained  natural.  In  analogous 
cases  in  man  it  is  probable  that  the  bacilli  reach  the  lungs  by 
means  of  the  blood-stream,  there  appearing  to  be  in  the  human 
subject  at  least  no  direct  lymphatic  connection  between  the 
cervical  glands  and  the  lungs  or  pleurae. ""^  In  other  experi- 
ments the  mesenteric  glands  have  alone  been  affected,  the 
bacilli  having  passed  through  the  intestinal  wall  without  leav- 
ing any  trace  of  their  passage.  It  may  be  admitted,  there- 
fore, that  the  lungs  are  in  some  cases  infected  by  bacilli  which 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  43 1 

have  been  swallowed,  and  have  entered  the  system  from  the 
alimentary  tract. 

Von  Behring^s  theory,  which  affirmed  that  pulmonary  tuber- 
culosis, though  not  congenital,  originates  commonly  in  early 
childhood  through  the  ingestion  of  infected  milk,  the  germ 
developing  and  the  disease  appearing  only  in  adult  life,  is 
negatived  by  the  fact  that  in  nearly  all  cases,  as  we  shall  show, 
phthisis  is  produced  by  bacilli  of  the  human,  not  the  bovine, 
type. 

Calmette  and  his  pupils,  among"  whom  may  be  mentioned 
Vansteenberghe  and  Grysez,"  following  von  Behring's  theory, 
urge  that  infection  through  the  alimentary  canal  is  not  the 
exception  but  the  rule,  and  that  phthisis  does  not  result  from 
the  direct  inhalation  of  tubercle  bacilli  into  the  lung,  but  that 
the  organisms,  whether  in  infected  dust,  droplets,  or  tuber- 
culous milk,  are  swallowed,  and  then  pass  to  the  mesenteric 
glands,  and  so  to  the  lungs.  Calmette  bases  his  conclusions, 
which  he  has  voiced  at  various  congresses,  on  experiments 
designed  to  show  that  phthisis,  or  tuberculosis  confined  to  the 
lungs  and  thorax,  can  be  produced  by  the  introduction  of 
tubercle  bacilli  into  the  alimentary  tract,  and  that  pulmonary 
anthracosis  is  not,  as  is  commonly  believed,  the  result  of  the 
inhalation  of  carbon  particles,  but  is  really  of  intestinal  origin. 
His  results,  however,  have  not  been  confirmed  by  Dr. 
Cobbett'^*  and  other  observers,  who  show  clearly  that 
pulmonary  anthracosis  as  well  as  phthisis  are  both  in  the  great 
majority  of  cases  the  result  of  an  inhalation  infection,  though 
it  is  not  denied  that  in  cases  of  alimentary  infection  the  lungs 
may  eventually  become  involved  when  the  disease,  after  affect- 
ing the  mesenteric  glands,  has  become  generalised.  This 
conclusion  is  supported  by  a  series  of  experiments  by  various 
observers,  notably  by  Findel"  and  Alexander,-*  which  prove 
that  a  much  larger  dose  of  bacilli  is  necessary  to  produce 
infection  through  the  alimentary  than  the  respiratory  tract. 
We  may  conclude,  therefore,  that  the  old  view  is  correct,  and 
that  in  the  aetiology  of  phthisis  the  main  channel  of  infection 
is  by  inhalation,  ingestion  playing  only  a  minor  role. 

Milk  Infection. — The  question  of  the  derivation  of  human 
tuberculosis  through  milk  or  butter  from  infected  cows  is  one 
of  importance,  involving  as  it  does  large  farming  interests 
and  State  measures  of  a  preventive  kind.     In  considering  this 


432  DISEASES   OF  THE  LUNGS   AND  PLEUR/E 

question,  we  must  carefully  separate  from  such  cases  those 
in  which  from  dirty  surroundings  milk  becomes  contami- 
nated by  tuberculous  dust,  thus  coming  within  the  category  of 
contaminated  foods.  The  question  now  under  discussion  is 
solely  concerned  with  milk  from  diseased  cows,  the  organism 
of  infection  being  the  bovine  tubercle  bacillus,  the  milk  thus 
coming  within  the  category  of  diseased  foods,  such  as  tuber- 
culous meat. 

There  have  been  two  Royal  Commissions  deaHng  inter  alia 
with  the  subject  of  tuberculous  milk,  and  both  reported 
strongly  in  favour  of  tuberculosis  arising  from  its  ingestion. 
Since  the  publication  of  the  Report  of  the  second  Commis- 
sion^" in  1907,  much  work  has  been  carried  out  in  differentiat- 
ing the  bacilli,  whether  of  human  or  bovine  type,  which  are 
to  be  found  in  the  various  forms  of  tuberculosis,  and  we  are 
now  in  a  position  to  speak  with  some  precision  on  this  subject. 
In  the  first  place,  it  has  become  clear  that  fatal  bovine  infec- 
tion in  the  adult  is  of  extreme  rarity,  hut  that  in  children  under 
five  years  of  age  it  is  not  uncomm^on.  Dr.  Cobbett,^"  to 
whose  work  we  are  much  indebted,  calculates  that  about  one- 
third  of  all  fatal  cases  of  tuberculosis  in  children  under  the  age 
of  five  is  attributable  to  a  bovine  source,  presumably  infected 
milk,  and  that  in  the  year  191 1  (the  returns  for  which  he  used 
in  his  calculations)  rather  over  3,000  deaths  could  be  traced  in 
England  and  Wales  to  this  cause. 

This  conclusion  is  based  on  the  following  evidence.  Bacilli 
of  bovine  type  have  not  hitherto  been  found  in  the  pulmonary 
lesions  of  phthisis.  In  the  sputum  from  nearly  a  thousand 
cases  examined,  in  only  four  were  bovine  bacilli  found,  the 
organisms  in  all  the  rest  being  of  the  human  type.  It  is  clear, 
therefore,  that  with  but  rare  exceptions,  pulmonary  tuber- 
culosis in  the  adult,  which  accounts  at  the  present  time  for 
7P  per  cent,  of  the  deaths  from  all  forms  of  tuberculosis,  is 
produced  by  bacilli  of  the  human  type,  and  is  the  result  of 
infection  from  human  sources,  and  in  our  efforts  towards  the 
eradication  of  the  disease  this  cardinal  fact  must  be  borne  in 
mind. 

With  regard  to  other  forms  of  tuberculosis,  according  to 
Dr.  Cobbett  some  17  per  cent,  of  cases  of  general  tubercu- 
losis (including  meningitis)  and  50  per  cent,  of  cases  of  fatal 
abdominal   tuberculosis   are   caused   by  bovine   bacilli,  both 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  433 

occurring-  mostly  in  children.  In  tuberculosis  of  the 
cervical  glands,  which  is  not  generally  fatal,  50  per  cent, 
of  the  cases  in  England  would  appear  to  result  from 
a  bovine  infection,  and  perhaps  70  per  cent,  in  Scotland, 
the  incidence  of  such  infection  being  much  higher  in  child- 
hood than  in  the  adult.  Of  cases  of  bone  and  joint  tubercu- 
losis, one  in  five  may  be  attributed  in  England  to  the  bovine 
type  of  bacillus,  and  in  Scotland  a  higher  proportion,  in  each 
case  the  percentage  in  childhood  being  much  greater  than  in 
the  adult.  From  an  analysis  of  the  figures.  Dr.  Cobbett  con- 
cludes that  roughly  6  per  cent,  of  all  cases  of  fatal  tuberculosis 
may  be  attributed  to  the  bovine  bacillus,  such  cases  occur- 
ring for  the  most  part  in  young  children,  and  two-thirds  of 
them  being'  of  the  abdominal  variety,  including"  ulceration  of 
the  bowel,  tuberculosis  of  the  mesenteric  glands,  and  tuber- 
culous peritonitis.  When  we  remember  that  in  addition  to 
these  fatal  cases  much  suffering  and  permanent  crippling  is 
caused  in  the  non-fatal  attacks,  especially  those  of  bone  and 
joint  tuberculosis,  a  considerable  proportion  of  which  are 
produced  by  the  bovine  bacillus,  we  see  that  the  danger  from 
infected  milk,  though  of  minor  importance  when  we  view  the 
subject  as  a  whole,  is  yet  one  by  no  means  to  be  ignored. 
It  is  fortunate  that  it  may  be  obviated  by  Pasteurising  the 
milk  or  raising  it  to  the  boiling-point. 

It  is  interesting  to  note  that  the  ethnographical  data 
collected  by  Dr.  Bruno  Heymann^^  support  the  conclusion 
thus  arrived  at  on  bacteriological  grounds  that  the  role 
played  by  infected  milk  in  the  dissemination  of  pulmonary 
tuberculosis  is  a  negligible  one,  and  that  this  form  of  tuber- 
culosis is,  in  fact,  spread,  as  we  have  urged,  by  the  inhalation 
of  infected  material  derived  from  human  sources.  This  ob- 
server showed  that  in  various  countries,  such  as  Greenland, 
the  Gold  Coast,  and  parts  of  Roumania,  where  milk  cannot 
possibly  be  obtained,  or  where,  as  in  Egypt,  it  is  too  dear  for 
the  natives  to  buy,  consumption  is  nevertheless  rife,  and  other 
forms  of  tuberculosis  are  often  met  with.  Further,  in  the 
Faroe  Islands  and  in  Japan,  tubercle  of  all  kinds  had  long 
been  frequent,  though  perlsucht  has  only  recently  been  intro- 
duced. 

The  Question  of  Contagion.— There  arises  out  of  a  considera- 
tion of  the  various  methods  of  infection  the  grave  question 

28 


434  DISEASES   OF  THE  LUNGS   AND   PLEURiE 

as  to  how  far  pulmonary  tuberculosis  is  a  contagious  disease, 
how  far  it  arises  from  a  person-to-person  infection  analogous 
to  that  by  which  the  contagia  of  measles,  smallpox,  and 
other  such  diseases  are  most  commonly  conveyed.  The  belief 
by  many  physicians  in  the  contagiousness  of  phthisis  is  not 
merely  of  laboratory  origin,  dating  from  the  demonstration 
of  the  tubercle  bacillus  :  it  has  existed  throughout  the  history 
of  medicine.  In  a  sense  it  is  true,  in  another  sense  it  is  greatly 
exaggerated.  It  is  true  in  the  sense  that  if  the  opportunities 
for  infection  are  intimate  and  prolonged,  and  proper  precau- 
tions against  the  spread  of  the  disease  are  not  forthcoming, 
so  that  massive  doses  are  absorbed,  as  happens  but  too 
frequently  in  the  "overcrowded  and  insanitary  dwellings  of  the 
poor,  then  direct  infection  may,  and  no  doubt  does,  occur. 

Of  patients  belonging  to  the  lower  middle  and  working 
classes  admitted  to  the  Brompton  Hospital,  only  about 
one-third  would  appear  to  be  aware  of  any  history  of  personal 
infection,  if  we  may  judge  from  the  loo  patients  under  the 
care  of  one  of  us,  in  whom  this  point  was  inquired  into  by 
Dr.  Wijeyeratne.  He  found  that  2"/  of  these  loo  patients  gave 
a  definite  history  of  exposure  to  domestic,  and  8  to  extra- 
domestic  infection,  at  some  time  previous  to  the  onset  of  their 
disease,  making  a  total  of  35  per  cent.  In  the  remaining  65 
no  history  of  the  kind  could  be  obtained.  In  certain  of  the 
cases  the  exposure  to  known  infection  had  occurred  several 
years  before,  and  it  must  not  be  forgotten  that  small  tuber- 
culous lesions,  such  as  a  caseous  area  in  a  lymphatic  gland, 
or  a  quiescent  nodule  in  the  lung,  may  remain  dormant  for 
long  periods,  to  break  into  active  disease  under  conditions 
of  anxiety  and  strain,  and  in  this  way  the  origin  of  cases  of 
phthisis  may  sometimes  be  traced  back  to  infection  in  earlier 
years  of  life. 

It  must  be  clearly  understood,  however,  that  the  contagious 
character  of  the  malady,  thus  admitted  under  certain  circum- 
stances, is  of  a  totally  different  order  from  that  met  with 
in  the  common  contagious  diseases  such  as  measles  and 
scarlet  fever.  In  the  latter  a  short,  even  a  momentary,  contact 
with  the  patient  is  sufficient  to  convey  the  disease.  In  phthisis, 
on  the  other  hand,  the  contact  must  be  intimate,  repeated, 
and  prolonged  to  be  effective,  and  even  then,  if  the  patient 
has  been  properly  trained  in  the  disposal  of  the  sputum  and 


ETIOLOGY   OF   PULMONARY  TUBERCULOSIS  435 

the  use  of  the  handkerchief  when  coughing,  and  regard  had 
to  cleanhness  in  the  surroundings,  and  to  proper  ventilation 
and  adequate  nursing  when  the  patient  is  bedridden,  there  is 
fittle  or  no  risk  of  infection.  In  the  upper  classes  tubercu- 
losis is,  as  a  rule,  acquired  rather  by  the  inhalation  of  dust 
from  public  waiting-rooms,  railway-carriages,  trams,  omni- 
buses and  the  like,  in  which  tubercle  bacilli  derived  from 
infected  sputum  have  not  infrequently  been  found. 

One  of  us  can,  however,  recall  the  case  of  a  wealthy  man 
suffering  from  consumption  and  living  in  a  large  house, 
whose  dirty  habits  led  to  the  infection  of  his  two  daughters, 
who  both  died  of  the  disease,  although  his  wife  escaped. 
Similarly  the  habits  in  regard  to  spitting  of  the  North 
American  Indians,  so  graphically  described  by  Dr.  Quevli^^ 
of  Tacona,  and  of  the  natives  of  South  Africa,  with  their 
ignorant  disregard  of  all  the  rules  of  hygiene,  explain  the 
rapid  spread  of  the  disease  among  these  people.  Wherever, 
also,  the  disease  is  freshly  introduced,  there  the  standard  of 
immunity  ranges  low. 

It  is  interesting  to  note  that  the  mouthpieces  of  public  tele- 
phones, even  when  used  by  consumptive  patients  (as  shown 
at  the  Brompton  Hospital  Sanatorium,  at  Frimley),  have  been 
found  on  investigation  to  be  free  from  tubercle  bacilli,  and 
should  not  be  regarded,  therefore,  as  sources  of  public 
danger,  provided  they  are  kept  properly  clean.* 

That  the  danger  of  personal  infection  is  not  great  if  proper 
precautions  are  taken  is  indicated  by  the  fact  that  in  con- 
sumption hospitals  and  large  sanatoria  the  disease  is  not 
abnormally  prevalent  amongst  the  officials  and  servants.  The 
observations  of  the  late  Dr.  Theodore  Wilhams,^^  upon  the 
health  of  the  staff  of  the  Brompton  Hospital  showed  that  at 
this  institution  during  the  years  1846  to  1882 — a  period  when 
open-air  treatment  was  not  practised,  and  when  the  ventila- 
tion of  portions  of  the  hospital  was  not  all  that  could  be 
desired — phthisis  did  not  develope  among  the  staff,  whether 
physicians,  assistant  physicians,  clinical  assistants  (house 
physicians),  or  nursing  and  general  staff,  some  of  whom  had 
lived  for  many  years  in  the  hospital,  more  frequently  than 

*  This  statement  is  based  upon  reports  by  Dr.  Klein,  and  more  recently 
by  Dr.  Spitta,  which  have  been  courteously  placed  at  our  disposal  by 
the  Postmaster-General. 


436  DISEASES   OF  THE  LUNGS   AND   PLEURA 

might  be  expected  in  any  large  institution  not  especially 
devoted  to  consumption,  or,  indeed,  in  any  urban  population. 
This  conclusion  was  based  upon  the  records  of  several 
hundred  persons  whose  life-histories  were  traced  for  many 
years  after  leaving  the  institution  by  the  then  Resident 
Medical  Officer,  the  late  Mr.  Vertue  Edwards.  More  recently 
Dr.  Theodore  Williams'*'*  published  statistics  of  the  medical 
staff  of  the  hospital  from  1882  to  1909,  which  yielded  similar 
conclusions,    though    it    should    be    noted    that    among    the 


Death 

1 

1 — r 

1 1 [ 1 1 1- 

Rate 

^^^^^*^ 

Phthiais   Death   Rates.  Males 

""^^ 

t^^              ENaLANoiWAi.ti  1651-1910 

3(500 

"•"••. 

//             /                        ,9°.-'' 

x^v 

3.000 

it       i                       .'                     ^y^ 

-1 1 ^X-- 

"•■■:V 

! !   .■••■    .y 

ZflOO 

.7/    .••       / 

r  i   .V       y       .s^.y 

'/  ■  ■■   y       .-^ 

' 

■•••N;-N\\ 

'//■•■■/  y 

'-v^A 

iioa 

^^  v  \ 

^■:\\ 

toco 

^■*^: 

500 

y 

A3= 

Period      1                  •                  1                  1                  1                  1 

1                 1 

1        1        1        1        1        • 

10                 15                 20                2i                30                35                40 

43                30 

i5                60                 65                 ro                 '5                60 

t  VV 

Fig.  42. 

From  Dr.  Brownlee's  Report  to  Medical  Research  Committee,  1918,  diag.  ii. 
In  this  and  the  following  diagram  (i)  the  general  decline  in  death- 
rate  from  phthisis  is  shown  in  successive  decades ;  (2)  the  curves  also 
show  the  far  greater  decline  at  the  earlier  ages  and  the  greater  rela- 
tive mortality,  especially  amongst  males,  between  the  ages  of  35  to  55 
in  the  later  decades. 

porters,  whose  duty  it  was  to  handle  and  sterilise  the  linen 
and  sputum,  two  deaths  from  phthisis  had  occurred. 

From  these  observations,  which  have  been  confirmed  by  the 
results  from  other  consumption  hospitals,  it  seems  clear  that 
the  danger  of  personal  infection  is  not  a  great  one,  provided 
that  common-sense  precautions  are  taken. 

The  observations  of  Sir  Hugh  Beevor^*  upon  the  prevalence 
of  phthisis  in  the  rural  districts  of  Norfolk  during  three 
succeeding  decades  (1861  to  1890)  are  also  interesting  in  this 
respect.     The  figures  show  that  in  each  decennium  the  death- 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS 


437 


rate  from  phthisis  in  these  small  rural  populations  (varying  in 
number  from  2,000  to  6,000)  was  in  each  remarkably  constant, 
nearly  always  falling  within  10  per  cent,  of  the  mean  rate  for 
that  of  all  the  rural  districts,  and  never  showing  those  marked 
irregularities  which  are  met  with  in  the  case  of  the  common 
epidemic  or  infectious  diseases.  The  figures  indicate,  as  Sir 
Hugh  Beevor  points  out,  that,  given  fairly  satisfactory 
surroundings,  the  influence  of  case-to-case  infection  sinks  in 
importance,  other  contributory  or  favouring  factors  playing 
the  chief  role.     The  steady  line  of  decline  of  the  tuberculosis 


Death 
Rabes 

pe 
Mill 

4,500 


3^00 


J.000 


2,500 


2,0na 


1,000 


Phthisis  Death  Rates.  Females  ) 
England  8c  Wales  I85I-I9I0 


•V-  /  •  ^ 


Age  Pertod 

10  15  20  25  30 


a  ■''0  4i  50  55  60  65  fO  '5  80 


Fig.  43. 

From   Dr.    Brownlee's   Report  to   Medical  Research   Committee,    1918, 

diag.   iii. 

death-rate  through  successive  decades  (see  Figs.  42  and  43) 
is  further  evidence  that  the  contagious  element  in  the  malady 
no  longer  resembles,  either  in  type  or  degree,  that  obtaining 
in  the  ordinary  contagious  diseases. 

Marital  or  Conjugal  Tuberculosis. — Evidence  in  favour  of 
personal  infection  has  been  deduced  from  the  cases  in  which 
the  disease  has  been  communicated  from  husband  to  wife,  and 
vice  versa;  and  the  remarkable  series  collected  by  the  late  Sir 
Hermann  Weber'''  of  nine  consumptive  husbands  who  lost 
eighteen  wives,  one  of  these  pathological  Bluebeards  being 


438  DISEASES   OF   THE   LUNGS   AND   PLEURA 

responsible  for  four,  another  for  three,  four  others  for  two, 
and  three  for  one  each,  was  very  striking.  Such  dramatic 
experience  is,  however,  quite  unusual,  and  the  exact  conditions 
under  which  these  people  were  living  are  not  stated.  Certainly 
in  the  upper  classes,  in  our  experience,  conjugal  tuberculosis 
is  uncommon. 

This  view  is,  however,  by  no  means  generally  accepted.  Dr. 
Ernest  Ward,^*^  Tuberculosis  Officer  for  South  Devon,  has 
recently  reported  a  series  of  cases  to  illustrate  the  frequency  of 
conjugal  tuberculosis,  amounting  to  over  50  per  cent.,  in  his 
district  amongst  the  working  and  lower  middle  classes;  but 
the  associated  conditions  are  not  stated,  and  we  can  only  con- 
jecture the  degree  of  overcrowding  or  general  insanitation 
that  could  produce  such  results,  and  to  which  the  parents  of 
households  would,  of  course,  be  exposed  with  some  excess  of 
intensity. 

Statistics  on  larger  lines  are  completely  adverse  to  such 
restricted  experiences,  and  when  closely  scrutinised  suggest 
that  any  slight  increase  of  vulnerability  observed  in  such  cases 
depends  upon  other  factors  besides  mere  contiguity.  Dr. 
Longstaff"  has  pointed  out  that,  seeing  how  prevalent  con- 
sumption is,  it  must  happen,  in  the  ordinary  course  of  events, 
that  husbands  and  wives  will  die  of  the  disease,  not  very 
infrequently  within  short  periods  of  each  other,  without  any 
question  of  infection  arising.  Basing  his  results  on  mathe- 
matical calculations  deduced  from  the  Registrar-General's 
Reports,  he  estimated  that  the  prevalence  of  conjugal  tuber- 
culosis was  not  greater  than  might  be  expected  as  a  matter  of 
coincidence. 

The  late  Dr.  E.  G.  Pope,  Professor  Karl  Pearson, 
and  Miss  Elderton,''*  also  investigated  the  subject  in  an 
elaborate  statistical  memoir,  and  concluded  that  consumption 
in  husband  and  wife  does  occur  more  frequently  than  can  be 
explained  by  the  doctrine  of  chances,  and  that  there  is  some 
sensible  but  slight  infection  between  married  couples.  On 
a  further  analysis  of  the  statistics  of  Dr.  Pope,  comparing 
them  with  calculations  of  his  own  and  of  Miss  Elderton  and 
others  engaged  in  his  laboratory.  Professor  Pearson"  con- 
cludes that  for  the  middle  and  professional  classes  there 
is  a  definite  marital  relationship  of  persons  with  simi- 
larity of  constitution  and  of  physical  and  psychical  attributes 


y$:T10L0GY  OF  PULMONARY  TUBERCULOSIS  439 

which  is  due  to  unconscious  selection  in  mating".  To  this  dis- 
position towards  marriage  manifested  by  persons  having 
similar  constitutions  and  attributes  he  gives  the  name  "  assor- 
tative  mating,"  and  he  thinks  that  it  may  account  for  the 
slight  excess  of  liability  to  infection  which  he  finds  to  exist 
amongst  married  people.  This  relationship  or  correlation 
holds  g'ood  for  eye  colour,  general  health,  tone  of  voice,  for 
certain  neuroses,  including  insanity,  and  other  features  which 
cannot  in  any  sense  be  regarded  as  of  infectious  origin.  The 
index  of  similarity  or  correlation  for  married  people  of  the 
same  social  status  with  reg"ard  to  phthisis — that  is,  their  rela- 
tive vulnerability  to  that  disease — is  almost  identically  the 
same  as  that  for  the  main  features  just  named,  and  may  be 
represented  by  the  decimal  0*24  to  0"28.  The  index  falls  in 
both  cases  as  we  descend  the  social  scale,  being  0'i6  for  the 
prosperous  poor  and  entirely  negligible  for  the  very  poor. 
It  seems  clear,  then,  that  the  increased  tendency  of  married 
couples  to  become  both  affected  with  phthisis,  sHght  as  it  is, 
is  not  wholly  attributable  to  direct  infection,  but  also  to  an 
increased  vulnerability  to  distributed  or  environmental  infec- 
tion. A  similar  conjugal  disposition  to  insanity  is  to  be  noted, 
only  with  increased  force — 0'3o;  and  to  alcoholism  with  still 
greater  intensity — 07.  Dr.  Goring*"  concludes  from  his 
separate  researches  that  "  there  is  no  evidence  of  marital  infec- 
tion." "  The  incidence  of  phthisis  in  both  husband  and  wife 
noted  by  Pope,  Greenwood,  and  others,  may  be  due  to  assorta- 
tive  mating." 

Another  point  of  great  importance  in  the  incidence  of 
phthisis  as  bearing  upon  the  question  of  direct  marital  infec- 
tion, and  a  fortiori  of  person  to  person  infection  generally,  is 
the  fact  pointed  out  by  Karl  Pearson^"''  that  the  probability  of 
the  offspring  of  a  tuberculous  father  or  mother  being  tuber- 
culous is  far  greater  than  the  probability  of  a  wife  or  husband 
being  similarly  attacked.  "The  father  is  twice  as  dangerous 
to  the  child  as  the  husband  to  the  wife !  The  mother  is  only 
very  slightly  more  dangerous  than  the  father  at  very 
early  ages." 

Heredity  wauld  thus  seem  to  be  the  supplementary  factor 
involved  in  assortative  mating,  which  may  account  for  the 
slightly  increased  number  of  instances  in  which  husband  and 
wife  are  both  involved  in  tuberculosis.    And  Professor  Pear- 


440  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

son,  in  confirmation  of  this,  finds  that  there  is  an  appreciable 
excess  or  concentration  of  heredity  to  tuberculosis  amongst 
the  forebears  of  married  people;  the  stocks  from  which  they 
are  drawn  having  a  correlation  in  this  respect  of  0-30.^^'^ 

It  is  worthy  of  special  note  that  amongst  the  very  poor, 
\vhere  assortative  mating  practically  does  not  obtain,  tubercu- 
losis is  much  more  prevalent  than  amongst  the  middle  and 
professional  classes,  the  intensity  of  the  environmental  infec- 
tion from  overcrowding  and  the  diminished  resistance  from 
adverse  conditions  of  life  already  considered  no  doubt 
accounting  for  the  difference,  conditions  which  are  intensified 
in  the  conjugal  relationship. 

If  we  accept  the  views  put  forward  in  the  above  sections 
their  bearing  on  prevention  is  obvious.  The  consumptive 
patient  who  is  properly  trained  and  willing  and  able  to  carry 
out  instructions  is  no  real  source  of  danger.  Still  less  should 
such  patients,  Avho  need  our  sympathy,  be  regarded  as  lepers 
to  be  shunned.  On  the  other  hand,  the  selfish  or  ignorant 
patient  who  disregards  all  precautions,  or  the  sufferer  who 
from  increasing  weakness,  lack  of  proper  nursing,  and  over- 
crowded surroundings  is  incapable  of  doing  what  is  required, 
becomes  a  grave  danger  to  his  fellows.  In  such  cases,  volun- 
tary segregation  and  the  admission  of  the  patient  to  a  home, 
or  hospital  is  the  fine  of  treatment  indicated.  Sir  Arthur 
Newsholme"  draws  an  interesting  parallel  between  the 
increase  of  institutional  treatment  and  the  decline  of  the 
phthisis  death-rate  during  the  latter  half  of  the  last  century. 
An  increased  provision  of  beds  for  advanced  cases  is,  how- 
ever, still  urgently  needed  in  not  a  few  localities.  We  shall 
further  consider  this  question  in  the  next  chapter. 

REFERENCES. 

^  Anatomical  Report  by  Professor  G.  Elliot  Smith,  F.R.S.,  and  Dr. 
D.  E.  Derry,  The  Archaological  Survey  of  Nubia,  Bulletin  No.  5,  Cairo, 
1910,  p.  21. 

-  "  Pott'sche  Krankheit  an  einer  agyptischen  Mumie  aus  der  Zeit  der  21 
Dynastic  (um  1,000  v.  Chr.),"  von  Grafton  Elliot  Smith  und  Marc  Armand 
Ruffer,  Zur  Historische  Biologie  der  Kranlzheitserreger ,  3  Heft,  Giessen, 
1910,  p.  9. 

^  A  Supplementary  Anatomical  Report  by  Dr.  F.  Wood  Jones,  The 
Arch  ecological  Survey  of  Nubia,  Bulletin  No.  i,  Cairo,  1908,  p.  38. 

*  Museum  No.  182,  B  and  C. 


ETIOLOGY   OF  PULMONARY  TUBERCULOSIS  441 

5  See  "  Etudes  sur  la  Tuberculose  :  preuves  rationnelles  et  experimentales 
de  sa  specificite  et  de  son  inoculabilite,"  par  J.  A.  Villemin,  Professeur 
agrege  a  I'Ecole  imperiale  du  Val-de-Grace.     Paris,   1868. 

"  For  original  experiments  bearing  upon  this  point,  and  for  an  admir- 
able resume  of  the  recent  literature  of  the  subject  at  the  time,  see  "A  Pre- 
liminary Note  of  Some  Experiments  on  the  Etiology  of  Tuberculosis,"  by 
Dawson  Williams,  M.D.,  The  Transactions  of  the  Pathological  Society  of 
London,  1884,  vol.  xxxv.,  p.  413. 

^  "  The  Streptotrichoses  and  Tuberculosis  "  (being  the  Milroy  Lectures 
for  1910),  by  Alexander  G.  R.  Foulerton,  F.R.C.S.,  D.P.H.,  F.C.S.,  p.  44. 
London,   1910. 

»  (i)  "  The  Chemical  Constitution  of  the  Tubercle  Bacillus,"  by  Dr.  W. 
Bulloch  and  Dr.  J.  J.  R.  Macleod,  The  Lancet,  1901,  vol.  ii.,  p.  81. 

(2)  "  The  Morphological  and  Physiological  Variations  of  the  Bacillus 
Tuberculosis  and  its  Relations  [a]  to  Other  Acid-Fast  Bacilli ;  (6)  to 
the  Ray  Fungus  and  Other  Streptothricese,"  by  William  Bulloch, 
M.D.,  Transactions  of  the  British  Congress  on  Tuberculosis ,  London, 
vol.  iii.,  p.  494. 

(3)  "The  Chemical  Constitution  of  the  Tubercle  Bacillus,"  by  William 
Bulloch,  M.D.,  and  J.  J.  R.  Macleod,  M.B.,  Journal  of  Hygiene, 
1904,  vol.  iv.,  p.   I.  ■* 

"  "  An  Enquiry  based  on  a  Series  of  Autopsies  into  the  Occurrence  and 
Distribution  of  Tuberculous  Infection  in  Children  and  its  Relation  to  the 
Bovine  and  the  Human  Types  of  Tubercle  Bacilli  respectively,"  by 
A.  Stanley  Griffith,  M.D.,  Reports  to  the  Local  Government  Board,  London, 
igi4,  p.   107. 

'"  See  "  Reports  on  the  Work  by  Dr.  Stenhouse  Williams,"  Fifth  Annual 
Refort  of  the  Medical  Research  Committee,  1918-1919,  London,   1919,  p.  3=;. 

"  "  Effect  of  Exposure  to  Liquid  Air  upon  the  Vitality  and  Virulence 
of  the  Bacillus  Tuberculosis,"  by  Harold  Svifithinbank,  Transactions  of 
the  British  Congress  on  Tuberculosis,  London,   1902,  vol.  iii.,  p.  657. 

'^  "  On  the  Distribution  of  the  '  Tubercle  Bacilli  '  in-  the  Lesions  of 
Phthisis,"  by  Percy  Kidd,  M.A.,  M.D.,  Transactions  of  the  Royal  Medical 
and  Chiriirgical  Society,  1885,  vol.  Ixviii.,  p.  87. 

"  See  "  Ueber  des  Vorkommen  von  Tuberkelbazillen  im  Kreisenden 
Blute  und  die  praktische  Bedeutung  dieser  Erscheinung,"  von  F.  Jessen 
and  Lydia  Rabinowitsch,  Deutsche  Medicinische  Wochenschrift,  1910, 
p.  1116. 

'*  See  "  The  Specific  Diagnosis  of  Pulmonary  Tuberculosis,"  by  A.  C. 
Inman,  M.A.,  M.B.,  The  Lancet,  1910,  vol.  ii.,  p.  1748. 

i«  (a)   The   Causes  of  Tuberculosis,  by  Louis  Cobbett,   M.D.,   F.R.C.S., 
Cambridge,   1917,  p.   134. 
{b)  Loc.  cit.,  pp.   145-150. 
(c)  Loc.  cit.,  chap,  xxvi.,  p.  657. 

"  "  Die  Bedeutung  der  Geflugestuberkulosebazillen  fiir  die  Tuberculose 
des  Menschen,"  von  Dr.  E.  Lowenstein,  Tuberculosis,  Berlin,  vol.  xiii., 
1914,  p.  211.    See  also  British  Medical  Journal,  1913,  vol.  ii.,  Epit.,  No.  126. 


442  DISEASES   OF  THE  LUNGS   AND   PLEURA 

^^  Die  Lehre  von  der  Kongenitalen  Tuberkulose  mit  besonderer  Beriick- 
sichtigung  der  Placentartuberkulose,  von  Dr.  Anton  Sitzenfrey.  Berlin, 
1909. 

"  Dr.  Heron,  in  his  work  on  Evidences  of  the  Communicability  of  Con- 
sumftion  (London,  1890),  in  an  appendix,  gives  details  of  a  large  number 
of  cases  of  tuberculosis  derived  from  accidental  inoculation  by  direct  injury 
from  broken  spittoons  and  other  means. 

^°  For  a  more  detailed  account  of  the  case  by  the  late  Mr.  Stanley  Boyd, 
see  the  Clinical  Journal,  June  26,  1901,  p.  147. 

2"  "  Versuche  an  Meerschweinchen  iiber  die  Aufnahme  inhalierter 
Tuberkelbazillen  in  die  Lunge,"  von  Dr.  Bruno  Heymann,  Zeitschrift  fUr 
Hygiene  und  Infektionskrankheiten,  Leipzig,   1908,  Band  Ix.,  p.  490. 

^^  "  Das  Schicksal  inhalierten  Schimmelpilzsporen.  Ein  Beitrag  zur 
Kenntniss  des  Infektionsweges  durch  Inhalation,"  von  Dr.  Ballin,  Zeit- 
schrift fiir  Hygiene  uttd  Infektionskrankheiten,  Leipzig,  1908,  Band  Ix., 
P-  479- 

^^  "  Untersuchungen  iiber  die  Infektion  mit  Tuberkelbazillen  durch 
Inhalation  von  trockenem  Sputum-Staub,"  von  Dr.  Kohlisch,  Zeitschrift 
fiir  Hygiene  und  Infektionskrankheiten,  Leipzig,  1908,  Band  Ix.,  p.  527. 

"  (i)  "  Report  on  a  Bacterial  Test  for  estimating  Pollution  by  Air," 
by  Dr.  M.  H.  Gordon,  Annual  Re  fort  of  the  Medical  Oficer  of  the 
Local  Government  Board  for  the  Year  1902-03,  London,  1904, 
p.  421. 

(2)  Refort  on  an  Investigation  of  the  Ventilation  of  the  Debating 
Chamber  of  the  House  of  Commons,  by  Dr.  M.  H.  Gordon. 
London,  1906. 

^*  See  three  valuable  memoirs  on  this  subject  by  P.  Chausse,  Annales 
de  Vlnstitut  Pasteur,  tome  xxviii.,  1914,  pp.  608,  720,  771. 

^*  The  Channels  of  Infection  in  Tuberculosis,  being  the  Weber-Parkes 
Prize  Essay,  1903,  by  Hugh  Walsham,  M.A.,  M.D.,  F.R.C.P.  London, 
1904. 

^^  See  "  The  Importance  of  the  Upper  Respiratory  Tract  in  the  Etiology 
of  Cryptogenetio  Infections,  especially  in  Relation  to  Pleuritis,"  by  George 
Bacon  Wood,  Fourth  Annual  Refort  of  the  Henry  Phiffs  Institute, 
Philadelphia,   1908,  p.   163. 

^'  "  Sur  rOrigine  Intestinale  de  I'Anthracose  Puhnonaire,"  par  P.  Van- 
steenberghe  et  Grysez,  Annales  de  Vlnstitut  Pasteur,  1905,  tome  xix., 
p.  787. 

28  '<  Vergleichende  Untersuchungen  iiber  Inhalations-  und  Fiitterungs- 
tuberkulose,"  von  Dr.  H.  Findel,  Zeitschrift  fiir  Hygiene  und  Infektions 
krankheiten,  Leipzig,  1907,  Band  Ivii.,  p.   104. 

^°  "  Das  Verhalten  des  Kaninchens  gegeniiber  den  verschiedenen 
Infektionswegen  bei  Tuberkulose  und  gegeniiber  den  verschiedenen  Typen 
des  Tuberkelbacillus,"  von  Dr.  Joh.  Alexander,  Zeitschrift  fiir  Hygiene 
und  Infektionskrankheiten,  Leipzig,  1908,  Band  Ix.,  p.  467. 

^°  Second  Interim  Refort  of  the  Royal  Commission  affointed  to  inquire 
into  the  Relatiotis  of  Human  and  Animal  Tuberculosis,  London,  1907. 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  443 

^'  "  Weitere  Beitrage  zur  Frage  iiber  die  Beziehungeo  zwischen 
Sauglingsernahrung  und  Tuberkulose,"  von  Dr.  Bruno  Heymann,  Zeit- 
schrijt  fur  Hygiene  und  Infektionskrankheiten,  Leipzig,  1908,  Band  Ix., 
p.  424. 

^^  {a)  "A  Lecture  on  the  Infection  of   Consumption,"   by  C.    Theodore 
Williams,   M.A.,   M.D.,  F.R.C.P.,  British  Medical  Journal,   1909, 
vol.   ii.,  p.  433. 
{b)  Loc.  cit.,  p.  435. 

^^  "The  Contagion  of  Phthisis,"  by  C.  Theodore  Williams,  M.A.,  M.D., 
F.R.C.P.,  British  Medical  Journal,  1882,  vol.  ii.,  p.  618. 

^*  Rural  Phthisis  and  the  Insignificance  of  Case-to-Case  Infection,  by 
Sir  H.  R.  Beevor,  Bart.,  M.D.,  F.R.C.P.     London,  1900. 

^^  "  On  the  Communicability  of  Consumption  from  Husband  to  Wife," 
by  Hermann  Weber,  M.D.,  Transactions  of  the  Clinical  Society  of  London, 
1874,  vol.  vii.,  p.   144. 

3"  "  Conjugal  Tuberculosis,"  by  E.  Ward,  M.D.,  F.R.C.S.,  The  Lancet, 
1919,  vol.  ii.,  p.  606.  See  also  a  leading  article  in  The  Lancet,  1919,  vol.  ii., 
p.  651,  and  various  letters  relating  to  this  subject. 

^'  Studies  in  Statistics,  by  George  Blundell  Longstaff,  M.A.,  M.B., 
F.R.C.P.,  p.  384.     London,  i8gi. 

'^  A  Second  Study  of  the  Statistics  of  Pulmonary  Tuberculosis :  Marital 
Infection,  by  Ernest  G.  Pope,  Karl  Pearson,  F.R.S.,  and  Ethel  M.  Elderton 
(Drapers'  Company  Research  Memoirs).     London,  1908. 

^'  Tuberculosis,  Heredity,  and  Environment,  by  Karl  Pearson,  Galton 
Professor  of  Eugenics,  University  of  London.     1912. 

[a]  Loc.  cit.,  p.  19. 

(b)  Loc.  cit.,  p.  16. 

"  On  the  Inheritance  of  the  Diathesis  of  Phthisis  and  Insanity,  by 
Ch.  Goring,  M.D.  (Drapers'  Company  Research  Memoirs  :  Studies  in 
National  Deterioration,  vol.  v.,  p.  24).     London,  1909. 

■*'  The  Prevention  of  Tuberculosis,  by  Sir  Arthur  Newsholme,  K.C.B., 
M.D.,  F.R.C.P.,  London,  1908,  chap,  xxxv.,  p.  266,  etc. 


CHAPTER  XXX 

PULMONARY    T\JBERCi:LOSlS—(Con/iiiued) 

etiology — (Continued) 

Let  us  now  consider  the  conditions  which  bring  about  that 
aptitude  for  the  reception  of  the  bacillus  which,  in  view  of  the 
manifold  opportunities  of  infection,  is  of  such  paramount  im- 
portance. 

I.  Constitutional  Liability.— Apart  from  all  other  aetiologi- 
cal  considerations,  the  constitutional  liability  to  tuberculosis 
must  be  taken  into  account,  this  constitutional  tendency 
being  most  purely  and  strikingly  manifested  in  hereditary, 
less  completely  so  in  acquired,  liability.  We  do  not  main- 
tain the  first,  and  it  would  be  absurd  to  argue  the  second 
as  being  independent  of  the  surrounding  climatic  and  social 
conditions  which  we  have  yet  to  discuss;  but  when  these 
have  been  allowed  for,  there  still  remains  to  be  considered 
the  personal  element  in  the  disease — the  character  of  the  soil 
as  opposed  to  that  of  the  seed — which  in  many  cases  exercises 
an  influence  which  cannot  be  gainsaid. 

The  constitution  of  a  man  has  been  defined  by  one  of  us  as 
"  his  build,  the  integrity  or  otherwise  of  the  tissues  of  which 
each  part  of  his  body  is  made  up,  and  the  wholesomeness  or 
otherwise  of  the  juices  with  which  they  are  bathed;  the  sum 
of  his  vital  force,  his  cell-quickening  power,  which  shall  bear 
the  call  of  judicious  expenditure  for  a  long  or  but  a  brief 
period  of  time."^  This  material  and  dynamic  constitution  is 
born  with  the  infant,  developed  during  the  period  of  growth, 
and  maintained  with  waning  completeness  during  the  wear 
and  tear  of  subsequent  life.  Hereditary  constitutional  defect 
means  unsoundness  of  original  construction  with  regard  to 
some  organ  or  tissue  at  birth.  Acquired  constitutional  defect 
means  that  some  part  of  the  human  mechanism  has  suffered 
deterioration  from  deficient  supply  of  the  needs  of  growth 

444 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  445 

and   function,   through   wilful   or  involuntary   exhaustion   of 
vital  powers,  or  from  imperfect  recovery  from  acute  disease. 

Inherited  Tendency  to  Phthisis. — In  considering  this  ques- 
tion, it  has  been  usual  to  quote  statistics  showing  that,  of  those 
suffering  from  consumption,  many  have  lost  a  parent  or  some 
near  relative  from  the  same  disease,  and  to  gauge  the  degree 
of  danger  from  the  resulting  figures.  Thus,  in  the  first 
medical  report  of  the  Brompton  Hospital,  of  the  i,oio  patients 
investigated,  a  history  of  consumption  in  one  or  other  parent 
(and  sometimes  in  both)  was  obtained  in  246  cases,  or  244  per 
cent.  Dr.  C.  J.  B.  Williams  and  Dr.  Theodore  Williams,- 
again,  taking  only  their  private  patients,  found  that,  of  1,000 
cases  carefully  investigated  by  them,  120  gave  a  parental 
history  of  the  disease,  while  in  484  some  near  relative  had 
fallen  a  victim.  The  conclusion  at  which  they  arrived  was 
that  "direct  hereditary  predisposition"  might  be  traced  in 
12  per  cent,  of  the  cases,  and  "family  predisposition"  in 
48  per  cent. ;  and  this  estimate,  coming  from  the  upper  classes, 
who  are  protected  from  many  of  the  more  potent  causes  of 
the  disease,  they  were  inclined  to  accept  as  a  fair  statement  of 
the  influence  of  hereditary  predisposition.  Our  own  experi- 
ence would  be  in  accord  with  these  results.  One  of  us,^ 
looking  back  upon  the  histories  of  450  cases  of  consumption 
taken  consecutively  from  case-books  of  a  few  years  previously, 
found  208  cases  with  a  definite  history  in  the  family,  123  with 
a  negative  history,  and  119  in  which  the  history  was  not  re- 
corded (most  of  these  latter  would  be  negative).  Of  the  208 
cases  with  positive  histories,  in  43  several  direct  relations  were 
affected  (father  and  mother,  4;  father  and  grandparents,  2; 
father  and  brother  or  sister,  5;  mother  and  brother  or  sister, 
II;  two  or  more  brothers  and  sisters,  20;  brother  and  grand- 
parents, i).  In  30  and  33  cases  respectively  the  father  or  the 
mother  was  affected,  yet  in  4  instances  only  were  both  involved, 
and  we  should  regard  this  as  in  excess  of  our  general 
experience. 

More  complete  data  were  collected  from  383  patients  at  the 
Crossley  Sanatorium,  Delamere  Forest,  by  Dr.  W.  C.  Rivers, 
and  were  discussed  in  an  interesting  memoir  by  Professor 
Karl  Pearson,*  who,  however,  was  careful  to  point  out  that 
the  investigation  was  preliminary,  and  that  his  conclusions 
needed    confirmation    from    more    extended    data.     After   a 


446  .  DISEASES   OF   THE   LUNGS   AND   PLEURA 

detailed  analysis  of  the  figures  by  modem  statistical  methods, 
he  concludes :  "  The  diathesis  of  pulmonary  tuberculosis  is 
certainly  inherited,  and  the  intensity  of  inheritance  is  sensibly 
the  same  as  that  of  any  normal  physical  character  (e.g.,  stature, 
span,  cubit,  eye-colour)  yet  investigated  in  man.  ...  A  theory 
of  infection  does  not  account  for  the  facts."  He  is  further 
"inclined  to  think  that  the  risks  run,  especially  under  urban 
conditions,  are  for  tuberculosis,  as  for  a  number  of  other  in- 
fectious diseases,  so  great  that  the  constitution  or  diathesis 
means  almost  everything  for  the  individual  whose  life  cannot 
be  spent  in  self-protection." 

A  reference  to  the  paragraph  on  "marital  infection"  in  the 
preceding  chapter  will  bring  to  mind  that  the  marital  relation- 
ship, in  the  more  intellectual  classes  at  all  events,  by  virtue  of 
the  unconscious  sexual  attraction  of  constitutional  affinities, 
brings  into  close  association  persons  with  a  somewhat 
stronger  strain  of  hereditary  predisposition  to  tubercle  infec- 
tion, and  that  amongst  them  there  is  therefore  an  increased 
vulnerability  to  any  environmental  conditions  tending  to 
tuberculosis. 

Let  us  now  ask  ourselves  how  far  Professor  Karl  Pear- 
son's conclusion  is  supported  by  clinical  experience.  All 
physicians  who  have  seen  much  of  phthisis  will  be  able 
to  recall  instances  in  which  one  member  after  another 
in  a  family  falls  a  victim  to  the  disease,  and  this  after 
the  individuals  have  grown  up  and  separated  widely.  A 
striking  example  of  this  has  come  under  our  notice.  A  lady, 
the  wife  of  a  country  gentleman  in  good  position,  died  of 
consumption  at  the;  age  of  forty-eight,  leaving  fifteen  children. 
Five  of  these  (daughters)  married  and  left  home,  and  subse- 
quently died  of  the  same  disease  at  the  approximate  ages  of 
forty-eight,  forty-nine,  thirty,  twenty-seven,  and  twenty-six 
respectively.  In  addition,  one  unmarried  daughter  developed 
consumption  and  died  at  San  Remo  at  the  age  of  nineteen, 
and  one  son  developed  phthisis  in  India,  and  died  in  Australia 
at  the  age  of  twenty-seven.  We  may  add  that  at  the  date  at 
which  the  facts  were  brought  to  our  notice  two  g'randchildren, 
aged  thirty-three  and  eighteen  (children  of  the  daughters 
above  referred  to  who  died  of  phthisis  at  the  ages  of  forty- 
eight  and  twenty-six  respectively),  had  also  developed  con- 
sumption. 


/ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  447 

It  will  be  urged  by  those  who  oppose  the  doctrine  of 
heredity  that  the  seven  out  of  the  fifteen  children,  who  thus 
developed  phthisis,  acquired  the  disease  because  they  were 
infected  from  their  mother  in  comparatively  early  life,  the 
organisms  then  remaining  dormant  for  years.  Such  a  proposi- 
tion is  not  impossible  in  view  of  the  fact  that  living  and  virulent 
tubercle  bacilli  may  be  found  post-mortem  in  caseous  and 
even  calcareous  foci  in  persons  who  during  hfe  had  not 
wittingly  suffered  from  tuberculosis.*  Even,  however,  if  we 
accept  the  correctness  of  the  assumption,  we  have  to  ask 
why  these  patients  eventually  developed  active  pulmonary 
tuberculosis.  Phthisis  is  an  exceedingly  common  complaint, 
and  the  opportunities  of  infection  under  ordinary  conditions 
of  civilisation  seem  infinite.  The  observations  of  Naegeli 
show  that  of  post-mortem  examinations  made  between  the 
ages  of  eighteen  and  thirty,  96  per  cent,  gave  evidence  of 
having  been  at  some  time  infected,  and  that  above  thirty  no 
individual  is  free :  yet  the  disease  does  not  develope  save  in  a 
restricted  percentage  of  the  population. 

It  appears  to  us  that  the  only  answer  lies  in  the  doctrine  of 
heredity,  the  inheritance,  as  it  has  been  termed,  of  a  "tuber- 
cular diathesis,"  rendering  the  soil  of  certain  family  constitu- 
tions more  suitable  for  the  growth  of  the  bacillus  than  that 
of  others,  so  that,  when  infected  with  a  suitable  dose  of  the 
virus,  such  individuals  succumb  when  their  more  fortunate 
brethren  escape. 

This  doctrine  is  no  fantastic  one,  and  is  only  what  we  might 
expect  if  we  consider  the  matter  from  a  biological  standpoint. 
The  bacillus  is  a  member  of  the  vegetable  kingdom,  and  it  is 
notorious  how  selective  such  organisms  are.  As  Sir  James 
Crichton-Browne  has  truly  said:  "The  seed  of  certain  plants 
will  grow  only  in  a  clay  soil,  while  those  of  others  will  sprout 
only  in  sand  or  chalk ;  and  mushrooms,  which  are  not  remotely 
allied  to  the  fission  fungi  or  bacteria,  are  nice  in  their  taste, 
and  refuse  to  increase  and  multiply  on  an  exhausted  bed  or 
one  of  unsuitable  material;  while  they  flourish  copiously  when 
their  spawn  is  spread  on  an  appropriate  nidus."  So  it  is  with 
the  tubercle  bacillus,  which  exhibits  this  same  selectiveness. 
It  refuses  to  grow  in  broth  or  on  agar-agar,  and  yet,  if  a  little 
glycerine  be  added,  growth  at  once  takes  place.  That  some 
sHght  modification  of  the  soil  in  certain  famiUes  should  favour 


448  DISEASES   OF  THE  LUNGS   AND  PLEUR.E 

or  inhibit  the  growth  of  the  organism  is  to  us,  therefore,  not 
surprising. 

If  this  doctrine  be  true,  we  should  expect  that  the  different 
races  of  mankind,  following  the  example  of  the  animal 
kingdom,  would  exhibit  a  different  liability  to  disease.  There 
is  some  evidence  to  show  that  this  is  so,  though  here  again 
it  is  difficult  to  separate  the  race  factor  from  the  other 
elements  in  the  causation  of  the  disease.  It  is  admitted,  how- 
ever, in  America  that  the  negro  is  very  liable  to  consumption, 
and  that,  when  acquired,  it  runs  in  him  a  rapid  course.  Among 
the  Jewish  race,  on  the  contrary,  the  mortality  from  phthisis, 
both  in  London  and  New  York,  as  in  most  of  the  great  cities 
of  Europe,  is  shown  by  statistics  to  be  less  than  that  of  the 
native  population,  and  it  is  not  impossible  that  this  lower 
death-rate  is  due  in  part  at  least  to  diminished  racial 
proclivity.^  Major  Johnston,  of  the  Indian  Medical  Service, 
has  also  shown  that  among  the  races  which  compose 
the  Indian  Army  there  is  a  marked  variation  in  the  incidence 
of  pulmonary  tuberculosis,  ranging  from  73  per  10,000  among 
the  Gurkha  soldiers  to  17-8  and  iS^o  per  10,000  among  the 
Sikhs  and  Mahrattas  respectively.  He  considers  that  the 
racial  factor  plays  a  definite  share  in  this  varying  liability.'' 

It  is  thus  clear  that  inheritance  is  an  important  factor  in  the 
aetiology  of  phthisis,  and  that  it  manifests  itself  in  a  special 
idiosyncrasy  of  the  tissues  in  certain  families  and  races 
whereby  they  become  more  than  usually  favourable  to  the 
growth  of  the  tubercle  bacillus.  It  is  only  right  to  add  that 
the  effect  of  this  factor  is  to  tend  to  eliminate  the  more  sus- 
ceptible, and  in  the  course  of  generations  to  increase  immunity 
amongst  the  survivors.* 

2.  Climatic  Causes. — Phthisis  flourishes,  as  we  have  said,  in 
every  climate,  and  it  is  not  possible  to  point  to  any  country 
which  has  a  monopoly  of  the  disease.  True,  the  death-rate 
from  consumption  differs  much  in  different  regions,  but  this 
would  seem  to  depend  in  great  part  not  so  much  upon  vary- 
ing meteorological  data  as  upon  other  factors  which  favour 
the  incidence  of  the  disease.  Wherever  the  population  is 
scattered  and  leads  an  open-air  life,  there  the  disease  is  less 
frequent.  Wherever  overcrowding  is  rife,  and  the  evils  of 
civilisation  are  apparent,  there  it  is  more  common.  There  are, 
however,  certain  climatic  factors  which  deserve  consideration. 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS 


449 


(a)  AltiUide. — Evidence  exists  to  show  that  phthisis,  though 
it  occurs  at  high  altitudes,  is  less  frequent  there  than  at  lower 
levels.  This  fact  was  noted  by  Dr.  Jourdanet,^  a  French 
physician  living  in  Mexico,  and  also  by  the  late  Dr.  Archibald 
Smith,  who  practised  at  Lima,  and  it  was  their  observations, 
including  the  good  effects  of  the  higher  regions  on  those  who 
acquired  phthisis  in  the  plains,  that  led  to  the  development 
of  the  Swiss  Alpine  resorts.  Dr.  Huggard'"  pubhshed  the 
following  statistics  dealing  with  the  prevalence  of  tuberculosis 
among  the  native  population  in  the  Canton  Grisons,  at 
different  altitudes,  in  the  year  1895  : 

Figures  from  the  Cantc^nt  Grisons,  showing  Diminished  Prevalence  of 
Tuberculous  Diseases  with  Increasing  Elevation. 


Number  of 
Communes. 

Elevation  above 

Sea-level  in 

Metres. 

Population. 

Average 

Population  of 

Commune. 

Affected 
with  Tuber- 
culosis (480  of 
the  690  Cases 
were  Examples 
of  Phthisis). 

Per 
Thousand. 

[a)   15          ... 
{b)  40         ... 
{c)   64 
{d)  19 

285-    599 

600-     999 

1,000-1,499 

1,500-1,880 

20,369 
20,935 
25,346 
10,291 

1358-0 

5234 
396-0 

541-6 

246 

204 

182 

58 

12-48 

9-74 
7-i8 

5-64 

The  table  indicates,  as  Dr.  Huggard  states,  "that  the  pre- 
valence of  tubercular  disease  diminishes  steadily  with  altitude, 
although  the  communes  of  greatest  altitude  are  more  populous 
than  the  two  groups  of  communes  next  below  them."  The 
figures  for  the  higher  regions  of  Switzerland  for  the  years 
1905-1909,  published  by  Dr  Schmid,^'  Director  of  the  Swiss 
Ministi-y  of  Health,  also  show  a  diminution  of  the  death-rate 
from  phthisis  and  tuberculosis  in  general  as  the  altitude 
increases.  It  would  seem  not  improbable  that  the  deeper 
respirations  required  at  these  higher  elevations,  leading  to 
improved  blood-supply  and  better  nutrition  of  the  lungs,  may 
explain  the  diminished  incidence  of  the  disease.  Dr.  William 
Gordon,'^"  of  Exeter,  casts  doubt  upon  the  influence  of  mere 
elevation,  and  would  attribute  much  of  the  good  effects  to  the 
absence  of  high  and  rain-bearing  winds.  These  conditions 
can,  however,  only  be  said  to  hold  good  during  the  winter 
season  when  the  snows  have  fallen. 

(h)  Dampness  of  the  Soil. — The  independent  researches  of 

29 


450  DISEASES   OF  THE  LUNGS   AND  PLEURA 

the  late  Sir  George  Buchanan"  in  England,  and  of  the  late 
Dr.  H.  I.  Bowditch^"*  in  the  United  States,  pointed  many  years 
ago  to  a  relationship  between  phthisis  mortality  and  wetness 
of  soil,  the  death-rate  rising  with  the  dampness  of  the  subsoil. 
Sir  George  Buchanan'^  also  observed  the  converse  as  one  of 
the  results  of  improved  surface  drainage — namely,  that  the 
death-rate  from  phthisis  fell  as  the  drying  of  the  subsoil  took 
place.  These  results  have  been  criticised,  but  the  observations 
of  Dr.  William  Gordon,'-"^  of  Exeter,  to  which  we  referred  more 
fully  in  our  last  edition,  lend  some  support  to  the  theory.  It 
may  be  said  in  brief  that  towns,  villages,  hamlets,  or  houses 
situated  at  or  near  undrained  localities  on  heavy,  impermeable 
soils  or  on  low,  level  ground,  and  whose  sites,  consequently, 
are  kept  damp,  are  more  suitable  for  the  development  of  con- 
sumption than  those  which  are  placed  on  dry  or  rocky  ground, 
or  on  light  porous  soils,  where  the  redundant  moisture  can 
easily  escape.^*' 

(c)  Exposure  to.  Wind. — The  influence  of  wind  in  relation  to 
phthisis  was  first  drawn  attention  to  by  the  late  Dr.  Haviland.^' 
More  recently  Dr  William  Gordon,"  has  devoted  much  atten- 
tion to  the  subject,  investigating  especially  the  effect  of  wind 
upon  the  mortality  from  phthisis  in  the  various  districts  of 
Devon.  The  conclusion  at  which  he  arrives  is  that  "popula- 
tions exposed  to  strong  prevalent  rainy  winds  have  a  higher 
death-rate  from  phthisis  than  populations  sheltered  from 
them."  Dr.  Brownlee  finds  this  to  hold  especially  with  the 
"young  adult  type"  of  phthisis.  The  matter  is  difficult  to 
prove,  so  many  other  factors  having  to  be  weighed  and  dis- 
counted. The  ill-effects  of  winds  may  be  in  part  direct,  but 
are  perhaps  more  largely  due  to  the  closing  of  doors  and  win- 
dows to  which  their  violence  often  leads. 

3.  Injury. — Cases  of  phthisis  occasionally  come  before  us  in 
which  the  symptoms  have  followed  an  injury  to  the  chest. 

We  can  recall  a  remarkable  case  of  the  kind,  that  of  a  medical  man, 
aged  44,  of  robust  physique,  who  dated  his  attack  definitely  from 
being  crushed  against  a  tree  in  Scotland  by  the  backing  of  his  motor- 
car, which  he  had  not  sufficiently  "  braked."  .Some  ribs  on  both  sides 
were  broken,  and  double  hydrothorax  followed,  with  effusion  into  the 
pericardium  and  pneumonia  of  the  left  lower  lobe.  In  the  blood- 
stained mucus  expectorated  a  few  tubercle  bacilli  were  found.  When 
sent  to  Sir  Douglas  Powell  by  Dr.  Burton,  of  Blackheath,  three  months 
later,  in  December,   1909,  there  was  some  shrinking  of  the  left  side 


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ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  45 1 

and  dulness  over  the  apex,  with  a  few  crackles  extending  to  the  fourth 
rib.  He  went  to  a  sanatorium,  where  the  sounds  became  dry,  and  he 
put  on  four  pounds  in  weight.  Six  months  later,  although  greatly 
improved,  there  were  still  a  few  bacilli  to  be  found.  Dr.  Burton  sent 
a  final  note  of  this  case,  stating  that,  in  the  summer  of  1910,  "  he  had 
no  further  trouble  with  his  lungs,  and  was  able  to  shoot,  and  could 
walk  most  of  us  off  our  legs."  In  1912  he  was  seized  with  acute 
appendicitis,  and  died  of  peritonitis  after  operation.  Dr.  Burton  knew 
him  well.  His  health  had  always  been  good  up  to  the  time  of  his 
accident.  His  mother  died  at  an  advanced  age;  his  father  early  in 
life,  but  the  cause  of  death  was  unknown.  He  had  three  children,  one 
of  whom  died  of  tuberculosis,  aged  nineteen. 

The  subject  of  "traumatic  tuberculosis"  has  been  recently 
discussed  by  Dr.  Parkes  Weber,"  and  it  is  probable  that  the 
cases  are  to  be  explained  by  the  injury  lighting  into  activity 
a  latent  focus  of  disease. 

4.  Social  Conditions. — Amongst  the  general  predisposing 
causes  of  tuberculosis  may  be  enumerated  insanitary  condi- 
tions of  life;  debility  ensuing-  upon  acute  illnesses;  debility 
attendant  upon  chronic  diseases,  such  as  alcoholism,  syphilis, 
anaemia,  and  gastric  affections;  hereditary  predisposition  and 
mental  unsoundness.  With  regard  to  most  of  these  factors 
there  is  no  need  for  any  special  remark.  It  is  fully  admitted, 
and  in  accord  with  general  experience,  that  those  affected  with 
chronic  disease  and  those  who  are  weakly  from  incomplete 
recovery  from  acute  illness  are  prone  to  be  attacked  by  tuber- 
culosis ;  that  is  to  say,  their  resistance  to  tuberculous  infection 
is  for  the  time,  or  permanently,  lessened  or  broken  down. 

An  examination  of  both  climatic  and  industrial  condi- 
tions predisposing  to  pulmonary  tuberculosis  cannot  fail 
to  convince  anyone  how  largely  they  are  connected  with 
conditions  that  fall  under  the  heading  of  "sociology,"  as, 
indeed,  we  have  already  indicated  when  discussing  the  ques- 
tion of  contagion.  Phthisis  is  essentially  a  scourge  of  what 
we  call  civilisation.  Its  rarity  among  nomadic  tribes  and 
aboriginal  races  in  all  climates,  its  prevalence  in  industrial, 
as  compared  with  agricultural  localities,  point  to  social 
rather  than  to  climatic  influences  as  predominant  in  the 
aetiology  of  the  disease.  All  the  depressing  conditions  of 
life — anxiety,  mental  strain,  disappointments,  poverty,  bad 
sanitation,  overcrowding,  alcoholic  excess,  debauchery — 
are  concentrated  at  the  centres  of  civilisation.     The  weakly 


452 


DISEASES   OF  THE  LUNGS   AND   PLEURAE 


are  helped  to  live;  scrofula,  syphilis,  rickets,  and  catarrhs, 
prevail;  the  general  tone  of  health  is  depressed;  recovery 
from  acute  specific  diseases,  such  as  measles,  whoop- 
ing-cough, influenza,  and  from  inflammatory  chest  diseases, 
is  less  complete,  and  germs,  putrefactive  and  other,  are  so 
rife  that  special  precautions  against  them  are  necessary  to 
secure  the  healing  of  wounds.  All  that  we  know  about 
phthisis  would  lead  us  to  expect  its  greater  prevalence  under 
these  conditions,  and  such  we  find  to  be  the  case. 

It  is  comforting,  however,  to  find  from  statistical  evidence 
that,  with  improved  sanitation  and  a  general  increase  in  the 

Diagram  showing  Death-Rate  pee  Million  living  from  {a)  All  Forms 
OF  Tuberculosis,,  (i>)  Phthisis  ;  England  and  W.^les,  1859-1908, 
corrected  for  Variations  of  Sex  and  Age  Constitution. 


No^e.—The  darker  shading  refers  to  phthisis.     (From  the  Registrar- 
General's  Annual  Report.'^) 

wage-earning  capacity  of  the  labouring  classes,  there  has  been 
a  marked  and  up  to  recently  a  continuous  decline  in  the  death- 
rate  from  this  disease.  This  is  well  brought  out  in  the  above 
diagram,  taken  from  the  Seventy-first  Annual  Report  of 
the  Registrar-GeneraV  whereby  it  will  be  seen  that  the  stan- 
dardised death-rate  from  phthisis,  and  also  from  all  forms  of 
tuberculosis,  has  been  steadily  decreasing.  Sixty  years  ago, 
it  will  be  noted,  the  annual  death-rate  from  consumption  was 
26  per  10,000  living,  between  two  and  three  out  of  every  1,000 
people  dying  annually  of  the  disease.  In  1908  it  was  only  11-15, 
barely  more  than  one  person  in  every  1,000  falling  a  victim. 


ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  453 

Through  the  courtesy  of  the  Registrar-General  we  are 
enabled  to  give  the  corresponding  figures  for  succeeding 
years,  thus  bringing  the  table  up  to  date.  The  standardised 
death-rates  for  phthisis  per  10,000  persons  living  are  as  fol- 
lows:  1909,  10-63;  1910.  988;  1911,  10-31;  1912,  9-91;  1913, 
9-60;  1914,  9-93.  It  must  be  noted  that  there  has  been  some 
check  in  the  rate  of  decHne  since  1895,  and  since  1914  a  posi- 
tive rise,  due  mainly,  though  perhaps  not  wholly,  to  war  con- 
ditions, the  following-  being  the  death-rates  for  the  war  years  : 
1915,  11-53;  1916,  12-30;  1917,  13-83;  1918,  15-20.  These  figures, 
for  reasons  given  in  the  Registrar-General's  Report  for  1917, 
exagg-erate  the  increase  in  the  mortality  from  tuberculosis 
which  has  undoubtedly  occurred,  both  among  males  and 
females.    We  shall  again  refer  to  this  subject. 

5.  Age. — Pulmonary  tuberculosis  may  occur  at  any  age,  its 
heaviest  incidence  being  between  the  ages  of  twenty-five  and 
forty-five.  The  late  Dr.  Bulstrode,-"  in  his  valuable  report  on 
"  Sanatoria  for  Consumption,"  pointed  out  the  important  fact 
that  the  age  of  maximum  mortality  from  phthisis  has  become 
postponed,  and  now  occurs  between  the  ages  of  forty-five  to 
fifty-five  in  males,  and  thirty-five  to  forty-five  in  females, 
instead  of  between  twenty  and  thirty-five,  as  was  the  case  in 
the  middle  of  the  last  century.  This  is  well  shown  in  the 
diagrams  which  we  have  reproduced  (pp.  436,  437)  from  Dr. 
Brownlee's"^  recent  paper,  which  demonstrate  also  that  the  fall 
which  occurred  during  the  latter  half  of  the  last  century  has 
been  most  marked  in  the  young  adult  period  of  life.  Dr. 
Brownlee  finds  that  the  age-period  of  phthisis  is  not  con- 
stant, as  generally  supposed,  for  different  parts  of  the 
country,  being,  for  instance,  much  earlier  in  the  Shet- 
land Islands  than  in  London,  and  he  draws  the  conclusion 
that  it  is  "not  one  disease  due  to  one  organism,  but  a  group 
of  diseases  due  to  a  group  of  organisms,  just  as  enteric  fever 
and  dysentery  have  proved  to  be."  He  speaks  of  three  types 
or  varieties,  the  "young  adult  type,"  the  "middle-age  type," 
and  the  "  old-age  type,"  in  which  the  commonest  ages  of  death 
are  from  20  to  25,  45  to  55,  and  55  to  65,  respectively.  The 
hypothesis  is  supported  by  the  fact  that  the  two  former  types 
at  least  have  a  markedly  different  geographical  distribution 
within  the  British  Isles.  An  examination  of  Dr.  Brownlee's 
interesting  diagrams  suggests  the  possibility  that  the  varia- 


454 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


tions  of  the  phthisis  mortality  in  certain  districts  are  due  to 
occupational  causes  rather  than  to  some  specific  difference  in 
the  tubercle  bacilli.  Nor  must  it  be  forgotten  that  the  inci- 
dence of  the  disease  must  be  reckoned  on  an  average  as 
occurring  some  years  before  its  mortality,  and  that  with 
improved  methods  of  treatment  this  interval  between  incidence 
and  mortality  is  steadily  lengthening.  This  postponement  of 
the  age  of  maximum  mortality  is,  however  explained,  a  fact 
of  great  importance,  in  that  the  victim  dies  at  an  age  when  his 
family  is  less  dependent  upon  him,  and  does  not  so  inevitably 
lead  to  that  privation  among  the  children  which  so  often  is 
responsible  for  the  further  spread  of  the  disease.  The  excep- 
tional conditions  of  war  service  under  which  so  many  of  our 
young  soldiers  have  lately  acquired  tuberculosis  may  tem- 
porarily, in  some  degree,  modify  the  age  of  maximum 
mortality. 

6.  Oyercrowding. — Taking  the  proportion  of  two  persons 
to  a  room  in  tenements  of  not  more  than  five  rooms,  as  the 
limit  of  occupational  sanitation,  and  reckoning,  all  numbers 
above  that  proportion  in  percentages  of  overcrowding,  it  has 
been  shown  by  Sir  Shirley  Murphy  that  in  London  the  death- 
rate  from  consumption  advances  directly  in  ratio  to  the  over- 
crowding. This  is  demonstrated  in  the  following  table,  taken 
from  the  Report  of  the  London  County  Council :  ^^ 


Phthisis  Death-Rates  in  Relation  to  Overcrowding. 

London,  1901-1909. 
{Taking  two  persons  per  room  in  five-room  tenements  as  the  basis.) 


Proportion  of  Over- 
crowding in  Each  Group  of 
Sanitary  Areas. 

Crude 

Phthisis 

Death-rate 

per  1,000 

Persons 

living. 

Standard 
Death-rate. 

Factor  for 
Correction  for 
Age  and  Sex 
Distribution. 

Corrected 

Death-rate 

per  1,000 

Persons 

living. 

Corrected 

Death-rate 

(London, 

1,000). 

Under    7-5  per  cent. 

7-5  to  12-5 
12-5    ,,    20-0 
20-0    ,,    27-5 

Over      27-5 

I '034 
1-320 

i"4i3 
1-924 

I  "953 

17T8 
1-705 
I -771 
1-805 
I -651 

1-00991 
I -01 761 
0-97969 
0-96124 
I  05090 

1-044 
1-343 
1-385 
1-850 
2-052 

709 

912 

941 

1,256 

1.394 

London         

1-472 

1735 

I  -ooooo 

1-472 

1,000 

ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  455 

From  the  above  figures  it  is  to  be  seen  that  in  groups  of 
sanitary  districts  in  London  with  under  7-5  per  cent,  of  over- 
crowding the  corrected  death-rate  from  phthisis  was  1044 
per  1,000  people  hving.  As  the  overcrowding  increased,  so 
did  the  phthisis  death-rate,  until,  with  27-5  per  cent,  or  more 
of  overcrowding,  the  corrected  death-rate  reached  2-052. 

The  importance  of  overcrowding  as  a  factor  in  the  spread 
of  the  disease  is  also  shown  by  the  fact  that  in  Aberdeen,-^  as 
stated  in  1916  by  the  Medical  Officer  of  Health,  fully  one-half 
of  the  cases  of  phthisis  notified  were  found  to  be  occupying 
the  same  bed  with  other  inmates,  and  that  at  least  two-thirds 
were  sleeping  with  others  in  the  same  room.  A  very  similar 
condition  would  appear  to  prevail  in  Bradford."' 

7.  Dusty  Employment. — The  effect  of  dust  inhaled  in  the 
pursuit  of  various  employments  was  carefully  investigated 
many  years  ago  by  the  late  Dr.  Greenhow,-'  and  his  conclu- 
sions as  to  its  baleful  influence  and  the  excessive  mortality 
from  lung  diseases  and  phthisis  which  results  from  it,  have 
been  borne  out  by  later  observers. 

This  subject  we  have  referred  to  in  the  chapter  deal- 
ing with  pneumonokoniosis,  and  we  may  recall  that  it 
is  in  the  trades  in  which  the  dust  particles  are  hard  and 
gritty,  such  as  gold-mining,  tin-mining  and  lead-mining,  and 
among  cutlers,  potters  and  grinders,  that  the  danger  is 
greatest.  Soft  particles,  such  as  coal  dust  and  the  animal 
dusts  produced  from  bone,  horn  or  ivory,  are  less' harmful,  and, 
indeed,  among  coal-miners  the  mortality  from  phthisis  is  below 
the  average.  These  facts  are  illustrated  by  the  researches  of 
Dr.  John  Tatham,-'^  who  showed  that  for  the  three  years  1890 
to  1892  the  death-rate  from  phthisis  among-  potters,  lead- 
miners,  cutlers  and  file-makers  was  between  three  or  four 
times  that  of  the  agricultural  labourer,  whilst  among  tin- 
miners  it  was  nearly  five  times  as  great,  and  these  figures  are 
fully  maintained  in  the  recent  Reports  for  1918  and  1920  by 
Dr.  Brownlee.  The  mortality,  in  fact,  among  tin-miners 
proved  higher  than  that  of  any  other  trade  examined,  the  other 
four  mentioned  coming  next  in  order  of  frequency.  Dr. 
Tatham's  figures  show  also  in  the  dusty  trades  a  greatly 
increased  mortality  from  other  diseases  of  the  respiratory 
organs. 

The    observations    of    Dr.    Scurfield,-'    Medical    Officer    of 


456 


DISEASES   OF   THE  LUNGS   AND   PLEURA 


Health  for  Sheffield,  are  also  of  importance,  demonstrating 
that  although  the  total  death-rate  from  tuberculosis  in 
Sheffield  shows  nothing  peculiar,  yet  on  analysis  it  is  found 
that  the  male  death-rate  is  much  greater  than  that  for  England 
and  Wales,  while  the  female  mortality  is  much  smaller. 
Further  examination  shows  that  the  excessive  mortality 
from  phthisis  among  the  Sheffield  males  is  due  to  the  great 
prevalence  of  the  disease  among  the  grinders,  and  to  a  less 
extent  among  the  cutlers.  The  following  figures  abridged 
from  his  table  are  instructive,  showing  that  amongst  the 
grinders  half  the  mortality  is  due  to  consumption,  and  two- 
thirds  to  diseases  of  the  respiratory  system,  as  opposed  to 
one-sixth  and  one-third  respectively  among  the  total  male 
population  of  the  town.  The  same  holds  good  with  the 
Cornish  miners.^* 

Mortality  at  Sheffield  among  Male  Workers  in  Certain  Trades 
DURING  the  Seven  Years  (1901-1907). 


Occupations. 

Numbers. 

Mortality  (Rate  per  Thousand  living). 

All  Causes. 

Phthisis. 

Respiratory 
Diseases. 

Grinders        

Cutlers           

Tailors 

Printers          

Joiners           

3.868 

3,889 

941 

487 

2,286 

30-9 
300 
21-4 
17-3 
13 '9 

15-0 
6-0 

1-4 
3-8 
17 

5-6 
7-0 

4'i 
2-6 

2-6 

All  males  (1905-6-7) 

— 

l6"2 

2-6 

21 

A  consideration  of  the  above  facts  can  leave  no  doubt  as  to 
the  danger  resulting  from  the  inhalation  of  irritating  dusts, 
the  damaged  lung  being  thereby  rendered  more  easily  a  prey 
to  invasion  by  the  tubercle  bacillus. 

8.  Alcohol. — This  is  believed  by  many  to  be  a  potent  factor 
in  the  aetiology  of  the  disease,  and  French  statistics  are  quoted 
as  showing  a  parallelism  between  the  death-rate  from  tubercu- 
losis and  the  amount  of  alcohol  consumed.  In  England, 
according  to  our  experience,  the  majority  of  phthisical  patients 
show  no  evidence  or  history  of  alcoholism,  and  for  ourselves 
we  doubt  whether  alcohol  is  per  se  a  favouring  agent  to 
tubercle.  There  can  be  no  question  that,  if  taken  in  such 
excess  as  to  produce  the  di&eases  of  chronic  alcoholism — 


Diagram  I.— Showing  the  Percentages  of 


FIG.    44 
Phthisis  Deaths  to  Total  Deaths  of  Persons  from  all  Causes, 


,,,„,\S< 1J5,     ,L    1671    L    1691    1701     1711     1721    1731    l?4l     1751    1761    177,     176.    ^1    .801    IBI.     1621    .631    m,     l»S.    .661     IB7.     IBBI    1091    ,90.    ,9.,   .9,9 

Diagram  11  -Shoiviso  I'ercisniaoi!  of  P,iT,i,s,s  Deaths  10  Total  Deaths  from  ale  Causes,   London.   .S51.1919,   Subdivided  fob 
Males,   Females,  and  Pebsoms.     (Dr.   Bbownlee,) 


.•CABSI351  I8S5  .SSI  1366  137.  1875  .88.  1836  1891  1896  1901  1906  1911  1916-19.9 

Diagram   111,— Showing  Deaths  from  Phthisis  as  Percentage  of  Deaths  from  all  Causes.  England  and     Wales.     (Prof.  Karl  Peakson,) 

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ETIOLOGY  OF   PULMONARY   TUBERCULOSIS  457 

cirrhosis,  alcoholic  bronchitis,  pharyngitis,  or  peripheral 
neuritis — it  does  beget  a  tendency  to  the  accjuisition  of 
tubercle;  even  then,  however,  the  disease  is  apt  to  run  a 
chronic  course.  A  more  important  way  in  which  chronic 
alcoholism  favours  tuberculosis  is  indirectly  by  leading  people 
into  dirty,  ill-ventilated,  and  contaminated  drinking-places,  in 
which  the  virus  of  tubercle  is  diffused. 

9.  Insanity. — Mental  unsoundness  is,  again,  in  all  probabihty 
only  indirectly  operative  in  the  aetiology  of  phthisis,  insane 
patients  being  admitted  into  asylums  which  have  been  in  the 
past  to  a  certain  extent  insanitary  and  overcrowded,  and  which 
are  liable,  from  the  habits  of  such  patients,  to  specific  contami- 
nation. The  yearly  average  of  1,809  deaths  from  phthisis  in 
lunatic  asylums  which  obtained  in  1912  to  1914  increased  to 
5,605  in  1918,^"  no  doubt  attributable  to  the  overcrowded  con- 
ditions that  prevailed  during  the  war. 

10.  Epidemic  Features. — We  may  finally  ask  whether  behind 
and  beyond  all  the  aetiological  factors  we  have  been  consider- 
ing there  may  not  be  some  other  influence  at  work  controlling 
the  incidence  of  tuberculosis.  We  annex  a  diagram  (Fig.  44) 
from  Dr.  Brownlee's  Report  in  1918  to  the  Medical  Research 
Committee  on  the  Epidemiology  of  Phthisis,"^  in  which 
he  illustrates  the  curve  of  death-rate  from  the  disease  in 
London,  which  he  has  traced  from  the  Registrar-General's 
Reports  and  such  information  as  is  available  before  they  were 
instituted.  Diagram  I.  depicts  a  long  epidemic  wave  of 
phthisis  through  the  whole  of  the  eighteenth  century,  reach- 
ing its  height  at  the  commencement  of  the  nineteenth  cen- 
tury, when  for  about  thirty  years  it  fluctuated,  accounting  for 
between  26  per  cent,  and  20  per  cent,  of  the  total  deaths,  and 
then  declined  to  about  10  per  cent,  at  the  end  of  the  century. 
Professor  Karl  Pearson  also,  in  general  agreement  with 
Brownlee,  further  shows  that  within  the  period  covered  by  the 
Registrar-General's  Reports,  from  1841  up  to  1910,  there  is 
evidence  of  the  disease  being  in  some  manner  governed  by 
influences  other  than  those  of  mere  environment.  As  will  be 
seen,  the  curves  of  mortality  for  the  whole  country  given 
in  Diagram  III.  show  a  moderate  declension  during  the 
first  thirty  years  in  which  the  Factory  Laws  were  in  force ;  a 
more  decided  decHne  during  the  second  period  of  twenty-five 
years,  from  1865,  when  general  sanitary  reform  prevailed;  and 


45 B  DISEASES   OF   THE   LUNGS   AND   PLEURA 

then  a  failure  proportionately  to  respond  in  the  third  period 
of  twenty  years  to  the  special  sanitary  and  therapeutic 
measures  based  upon  a  recognition  of  the  specific  cause  of 
the  disease.  This  latter  check  in  the  declension  of  the  death- 
rate,  it  will  be  observed,  began  before  the  war,  and  although 
increased  to  a  positive  rise  in  death-rate  during"  the  war,  is  not 
wholly  attributable  to  that  cause.  The  general  death-rate,  on 
the  other  hand,  remained  constant  through  the  first 
period  of  factory  laws,  and  then  fell  steadily  and  without 
check  through  the  second  and  third  periods;  in  the  last  period, 
indeed,  the  decline  being  still  more  marked.  When  we  come 
to  analyse  these  somewhat  discouraging  results  in  the  light 
of  the  detailed  statistical  researches  related  in  Dr.  Brownlee's 
two  reports  and  in  Professor  Karl  Pearson's  records,  to  which 
we  have  extensively  alluded,  some  very  instructive  facts  are 
disclosed,  and  some  interesting  speculations  are  raised  relating 
to  the  prevalence  and  biology  of  tubercle. 

We  have  already  referred  to  the  three  types  into  which  Dr. 
Brownlee  believes  phthisis  to  be  separable.  He  finds  that  the 
main  decline  for  the  last  sixty  years,  up  to  1910,  has 
been  due  to  a  diminished  mortality — from  1-52  to  024  per 
cent,  for  males,  or  nearly  7  to  i — amongst  the  lives  of 
the  young  adult  type  (age  twenty  to  twenty-five);  the  middle- 
age  type,  of  the  period  between  thirty-five  and  fifty-five,  main- 
taining practically  the  same  mortality  during  that  time — i'  12  to 
I -16  per  cent.  The  decline  in  mortality  amongst  the  younger 
lives  has  been  most  marked  in  towns;  in  country  districts  and 
exposed  situations  the  disease  amongst  them  being  propor- 
tionally more  prevalent.  Wind  and  weather  and  subsoil  take 
an  important  part  in  its  aetiology,  the  interesting  diagrams  in 
Dr.  Brownlee's  first  report  (1918)  showing  its  prevalence  in  our 
wind-stricken  districts  of  North  Scotland,  Wales,  and  Devon- 
shire.^^" It  is,  on  the  other  hand,  but  little  affected  by 
insanitary  environment. 

Amongst  the  lives  of  the  middle-age  type  the  decline 
in  death-rate  has  been  much  less  manifest,  and  has  been  in 
closer  conformity  with  the  general  death-rate.  This  type  pre- 
vails especially  in  urban  districts,  and  a  glance  at  Dr.  Brown- 
lee's diagrams  will  show  a  much  closer  association  with  indus- 
trial conditions.  All  the  occupational  causes  of  phthisis  are 
mainly  operative  towards  the  middle  periods  of  life.     And  it  is 


.ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  459 

in  accord  with  experience  that  hereditary  influence  is  a  more 
important  factor  in  the  young  adult  period,  whilst  in  the 
middle-age  period  the  disease  is  more  definitely  acquired,  from 
prolonged  exposure  to  adverse  environment,  combined  with 
other  exigencies  in  the  struggle  and  harassment  of  middle  life. 
There  are  some  considerations  that  militate  against  any  dog- 
matic acceptance  of  the  first  two  types  of  phthisis  as  having 
been  fully  established.  Dr.  Brownlee  suggests  them  without 
dogmatism.  In  his  statistics,  which  are  of  death-rates  only, 
some  qualification  is  perhaps  needed  from  the  fact  that  many 
young  people  afflicted  with  chest  delicacy  or  actual  disease  in 
urban  districts  are  sent  away  to  the  country,  whilst  many 
cases  "recover"  under  treatment,  and  with  a  recurrence  in 
later  years  such  cases  tend  to  load  the  middle-age  group. 

It  would  appear,  from  a  due  consideration  of  all  the  circum- 
stances of  aetiology,  that  the  tubercle  bacillus  is  sufficiently 
ubiquitous  to  render  all  persons  liable  to  attack;  and,  indeed, 
most  persons  under  civilized  conditions  of  life  are  at  some 
time  or  other  attacked;  but  that  under  conditions  of  concen- 
tration of  the  poison  in  overcrowded  localities  and  in  dirty  and 
dust-laden  environments  the  contagion  may  be  so  strong  as  to 
be  operative  against  the  resistance  of  those  who  have  no 
original  constitutional  liability  to  the  disease.  The  here- 
ditary factor  tends,  on  the  one  hand,  to  increased  vulnerability 
to  early  attack,  and,  on  the  other,  to  gradual  increase  of  im- 
munity of  the  race  by  extinction  of  the  more  susceptible  and 
survival  of  the  more  resistant. 

The  biology  of  the  tubercle  bacillus  has  yet  to  be  traced  to 
its  probable  saprophytic  ancestry,  and  the  morphology  of  its 
parasitic  phases  to  be  further  disclosed,  before  we  shall  be  in 
a  position  fully  to  understand  its  various  types  and  degrees  of 
virulence,  the  reactions  of  its  host,  the  animal  organism, 
with  regard  to  it,  and  the  abiding  source  of  its  continuance 
through  the  ages.  As  remarked  by  the  Research  Committee 
in  their  introduction  to  Dr.  Brownlee's  first  report  of  1918,  the 
decline  in  mortality  in  past  decades  "is  most  naturally  to  be 
regarded  as  the  ebb  of  a  long  epidemic  wave,  to  be  succeeded 
perhaps — indeed,  probably — by  the  rise  of  the  next  wave  in 
its  turn,  unless  science  can  find  the  way  of  interference,  and 
its  explanation  can  only  be  given  by  further  study." 


460  DISEASES  OF  THE  LUNGS   AND  PLEURAE 

Our  primary  efforts — perhaps  better  directed — to  maintain 
its  decadence  must  not  be  relaxed;  but  tlie  true  biology  of 
the  disease  has  yet  to  be  found. 


REFERENCES. 

^  "  On  the  Causative  Relations  of  Phthisis,"  by  R.  Douglas  Powell, 
M.D.^  British  Medical  Journal,  1884,  vol.  ii.,  p.  701. 

2  Pulmonary  Consumption,  by  C.  J.  B.  Williams,  M.D.,  LL.D.,  F.R.S., 
and  Charles  Theodore  Williams,  M.A.,  M.D.,  second  edition,  p.  62. 
London,   1887. 

^  Lecture  to  the  Twenty-second  Congress  of  the  Royal  Sanitary 
Institute  at  Glasgow,  July,  1904,  "  On  the  Prevention  of  Consumption," 
by  Sir  R.  Douglas  Powell,  Bart.,  K.C.V.O.,  M.D.,  F.R.C.P.,  Journal  of 
the  Royal  Sanitary  Institute,  vol.  xxv.,  p.  354. 

*  A  First  Study  of  the  Statistics  of  Pulmonary  Tuberculosis,  by  Karl 
Pearson,  F.R.S.  (Drapers'  Company  Research  Memoirs  :  Studies  in 
National  Deterioration).     London,   1907. 

^  The  Causes  of  Tuberculosis,  by  Louis  Cobbett,  M.D.,  F.R.C.S., 
pp.  70-72.    Cambridge,  1917. 

s  "  Tuberculosis  and  the  Jew,"  by  W.  M.  Feldman,  M.B.,  B.S.  Lond., 
The  Tuberculosis  Year  Book  and  Sanatoria  Annual,  London,  1913,  vol.  i., 
p.  48.  See  also  an  interesting  article  entitled  "  Tuberculosis  among  Jews," 
British  Medical  Journal,  igo8,  vol.  i.,  p.   1000. 

'  "  Tuberculosis  in  the  Indian  Army  :  Its  Incidence  as  Affected  by 
Locality,  Racial  Proclivity  and  Service  Generally,"  by  Charles  A. 
Johnston,  M.B.,  CM.,  D.P.H.,  British  Journal  of  Tuberculosis,  London, 
January,   1908,  vol.  ii.,  p.  20. 

8  See  "  The  Laws  of  Heredity,"  by  G.  Archdall  Reid,  M.B.,  F.R.S.E., 
pp.  453,  455.  London,  1910.  In  various  parts  of  his  interesting  work 
Dr., Reid  alludes  to  this  subject. 

^  Le  Mexique  et  VAmerique  Troficale,  par  D.  Jourdanet,  p.  295. 
Paris,  1864. 

"  Handbook  of  Climatic  Treatment,  by  William  Huggard,  M.D.,  p.  124, 
London,  1906. 

^^  "  Die  Tuberkulosesterblichkeit  der  Schweiz  und  die  zur  B'ekampfung 
der  Tuberkiilose  daselbst  im  Letzen  Jahrzehnt  gemachten  Anstrengungen." 
von  Dr.  Schmid,  Direktor  des  Schweizerischen  Gesundheitsamts  in  B'ern, 
Tuberculosis,  Berlin-Charlottenburg,  vol.  xi.,  1912,  p.  357. 

■■^  [a)  "  The  Influence  of  Soil  on  Phthisis  as  illustrating  a  Neglected 
Principle  in  Climatology,"  by  William  Gordon,  M.A.,  M.D., 
F.R.C.P.,  British  Medical  Journal,  1909,  vol.  ii.,  p.. 840. 
(^)  The  Influence  of  Strong,  Prevalent ,  Rain-bearing  Winds  on  the 
Prevalence  of  Phthisis,  by  Williajn  Gordon,  M.A.,  M.D.,  F.R.C.P. 
London,  1910. 


.ETIOLOGY  OF  PULMONARY  TUBERCULOSIS  461 

(c)  "  The  Influence  of  Strong,  Prevalent,  Rain-bearing  Winds  on  the 
Course  of  Phthisis,"  by  William  Gordon,  M.D.,  F.R.C.P.,  Brtitsk 
Medical  Journal,  1912,  vol.  i.,  pp.  291  and  773. 

[d]  "  The  Place  of  Climatology  in  Medicine,"  being  the  Samuel  Hyde 
Memorial  Lectures  for  1913,  by  William  Gordon,  M.A.,  M.D., 
F.R.C.P.     London,   1913. 

^^  "  Report  by  Dr.  Buchanan  on  the  Distribution  of  Phthisis  as 
Affected  by  Dampness  of  Soil,"  Re-port  of  the  Medical  Officer  of  the  Privy 
Council,  London,  1867,  p.  57. 

^*  Consumftion  i^i  New  England,  or  Locality  One  of  its  Chief  Causes, 
by  Henry  I.  Bowditch,  M.D.     Boston,   1862. 

^5  "  Report  by  Dr.  Buchanan  on  the  Results  which  have  hitherto  been 
gained  in  Various  Parts  of  England  by  Works  and  Regulations  designed 
to  Promote  the  Public  Health,"  Refort  of  the  Medical  Officer  of  th'e 
Privy  Council,  London,  1866,  p.  40. 

^^  Seventh   Detailed  Annual   Report   of   the   Registrar-General   in    Scot- 
land, p.  xlviii. 

1'^  The  Geographical  Distribution  of  Disease  in  Great  Britain,  by 
Alfred  Haviland,  M.R.C.S.,  etc.,  late  Lecturer  on  "  The  Geographical 
Distribution  of  Disease"  in  St.  Thomas's  Hospital,  London.  Second 
edition.     London,  1892. 

1^  Traumatic  Pneumonia  and  Traumatic  Tuberculosis,  by  F.  Parkes 
Weber,  M.A.,  M.D.,  F.R.C.P.     London,  1916. 

^^  Seventy-first  Annual  Report  of  the  Registrar-General  of  Births, 
Deaths,  and  Marriages  in  England  and  Wales,  p.  ci.     London,   1909. 

2"  Re-port  on  Sanatoria  for  Consumption  and  Certain  Other  Aspects  of 
the  Tuberculosis  Question,  hy  H.  Timbrell  Bulstrode,  M.D.  (Supplement  to 
the  Thirty-fifth  Annual  Report  of  the  Local  Government  Board,  1905-06), 
p.  42.     London,  1908. 

'^1   An  Investigation  i^tto  the  Epidemiology  of  Phthisis  in  Great  Britain 
and  Ireland,  by  John  Brownlee,  M.D.,  D.Sc.   (Director  of  the  Statistical 
Department,  Medical  Research  Committee).     London,  1918. 
{a)  See  also  Part  iii.     London,  1920. 

^^  "  Report  of  the  Medical  Officer  of  Health  of  the  County  of  London  for 
the  Year  1909,"  London,  p.  58. 

23  See  British  Medical  Journal,  June,  1916,  vol.  ii.,  p.  886. 

'^  "Alcohol,  Housing  Conditions,  and  Consumption,"  by  Harold Vallow, 
M.D.,  British  Medical  Journal,  1914,  vol.  i.,  p.  477. 

25  <t  £)j-  Greenhow's  Reports  on  Districts  with  Excessive  Mortality  from 
Lung  Diseases,"  Report  of  the  Medical  Officer  of  the  Privy  Council, 
London,  i860,  p.  102,  and  1861,  p.  138. 

26  "  The  Mortality  of  Males  engaged  in  Certain  Occupations  in  the 
Three  Years  1890-92,"  by  John  Tatham,  Esq.,  M.A.,  M.D.,  Supplement  to 
the  Fifty-fifth  Annual  Report  of  the  Registrar-General,  part  ii.,  p.  xcvi. 
See  also  Dr.  Brownlee's  Reports  [loc.  cit.)  for  1918,  diagram  xx.,  and  for 
1920,  table  xxi.,  p.  97. 


462  DISEASES   OF  THE  LUNGS   AND   PLEUILE 

27  "  Notification  of  Tuberculosis  of  the  Lung  in  Sheffield,  and  the  Inci- 
dence of  Tuberculosis  on  Males,  Females,  and  Children  in  Various  Towns," 
by  H.  Scurfield,  Medical  Officer  of  Health,  Sheffield,  British  Medical 
Journal,  1909,  vol.  ii.,  p.  462.     See  also  ibid.,  1908,  vol.  ii.,  p.  480. 

28  Report  to  the  Secretary  of  State  on  the  Health  of  Cornish  Miners, 
by  J.  S.  Haldane,  M.D.,  F.R.S.,  Joseph  S.  Martin,  and  R.  Arthur  Thomas. 
London,   1904. 

^'  "  The  Check  to  the  Fall  in  the  Phthisis  Death-Rate  since  the  Discovery 
of  the  Tubercle  Bacillus  and  the  Adoption  of  Modern  Treatment,"  by  Karl 
Pearson,  F.R.S.,  Biometrika,  vol.  xii  ,  Nos.  3  and  4,  November  26,  1919, 
P-  2,7^- 


CHAPTER  XXXI 

PULMONARY    TUBERCULOSIS— (Continued) 

Pathology. 

On  inspecting  the  lungs  of  one  who  has  died  of  phthisis,  we 
meet  with  a  great  variety  of  appearances,  which  may,  never- 
theless, be  recognised  as  the  results  of  a  comparatively  few 
morbid  processes.  We  see  consolidation  of  the  lung  in  every 
stage  of  formation,  decay,  and  removal;  and,  glancing  at  the 
emaciated  form  before  us,  we  have  a  practical  definition  of 
phthisis  pulmonalis  or  consumption — viz.,  progressive  con- 
solidation and  decay  of  the  lung  with  progressive  wasting 
of  the  body. 

This  destruction  of  lung  and  waste  of  body  are  associated 
with  two  striking  morbid  processes  in  the  lung:  (i)  the 
occurrence  of  the  characteristic  granulation  of  tubercle, 
disseminated  through  the  organ,  or  collected  into  nodular 
groups,  or  mingled  with  inflammatory  changes,  developing 
into  fibroid  tissue,  or  immediately  undergoing  necrotic 
change ;  (2)  the  appearance  of  areas  of  inflammation,  generally 
also  tuberculous  in  origin,  and  affecting  with  varying  degrees 
of  intensity  the  different  tissues  of  the  lung.  Such  in- 
flammatory processes  run  an  acute,  chronic,  or  chequered 
course,  and  usually  terminate  in  caseation  and  softening. 

In  addition  to  the  above,  two  further  processes  will  require 
our  attention  in  considering  the  pathology  of  the  disease,  viz. : 

(3)  the  penetration  of  the  lungs  by  secondary  organisms; 

(4)  the  pathological  changes  in  the  lungs  and  pleurae  which 
result  mechanically  from  the  respiratory  movements  of  the 
chest  wall.     Let  us  now  consider  each  in  turn. 

(i)  The  Tuberculous  Nodule. — The  tubercle  bacillus,  as  we 
have  seen  in  the  preceding  chapter,  is  brought  to  the  lung 
either  by  aspiration  into  the  fine  bronchi  or  alveoli,  or,  more 
rarely,  by  means  of  the  blood-stream,  from  some  more  or  less 

463 


N 


464  DISEASES   OF   THE  LUNGS   AND   PLEURA 

distant  part  of  the  body.  Whenever  it  finds  a  suitable  resting-- 
place  and  the  conditions  are  favourable,  it  commences  to 
develope,  and  to  cause  a.  proHferation  from  the  fixed  cells 
of  the  part,  whether  bronchi,  alveoli,  or  capillaries,  result- 
ing in  a  collection  of  epitheHoid  cells.  Later,  in  the  centre 
of  the  little  mass,  one  or  more  giant  cells  may  appear,  and  on 
the  exterior  a  zone  of  leucocytes,-  the  whole  thus  constituting 
the  perfect  microscopical  tubercle.  The  presence  of  giant 
cells  and  leucocytes  will  depend,  however,  to  a  great  extent 
upon  the  activity  of  the  disease.  If  virulent,  giant  cells  will 
be  but  rarely  seen;  if  less  active,  they  will  be  more  evident, 
and  leucocytes  proportionately  fewer.  Giant  cells  are  thus 
not  an  essential  part  of  tubercle,  as  was  once  imagined;  and, 
we  may  add,  they  are  not  restricted  to  it,  being  found  in  many 
other  morbid  products.  If  suitably  stained,  one  or  more 
tubercle  bacilli  will  probably  be  detected  in  the  nodule,  some- 
times within  the  giant  cells,  but  in  the  human  subject  more 
commonly  between  the  cells.  No  vessels  are  present  in  the 
tubercles,  although  a  vascular  zone  often  surrounds  them. 
From  their  close  contiguity  to  vessels,  however,  their  nutrition 
is  assured,  until  the  toxines  excreted  by  the  contained  bacilli 
cause  their  degeneration  and  caseation. 

Wherever  started,  the  tuberculous  process  tends  quickly  to 
invade  adjoining  alveoli,  setting  up  a  tuberculous  broncho- 
pneumonia, which  is  very  apt  to  caseate,  the  patches  appear- 
ing to  the  naked  eye  as  minute  yellow  tubercles.  The  disease 
extends  by  aspiration  to  alveoli  as  yet  unaffected,  or  through 
the  lymphatics  to:  other  portions  of  the  lung.  In  acute  miliary 
tuberculosis,  when  life  is  rarely  prolonged  beyond  a  few 
weeks,  the  tubercles  at  the  time  of  death  are  transparent,  or 
only  just  commencing  to  caseate.  In  the  more  chronic  forms 
of  the  disease,  however,  we  often  meet  with  a  somewhat  larger 
and  firmer  variety  of  granulation,  hard,  semi-transparent, 
horny-looking,  and  of  about  the  size  of  a  pin's  head,  intimately 
connected  with  the  surrounding  tissue.  This  fibroid  trans- 
formation of  the  tubercles  occurs  especially  in  those  which 
have  their  origin  in  lymphatic  vessels  or  in  the  interstitial 
connective  tissue  of  the  lung,  the  alveoli  being  but  little 
involved. 

In  order  to  apprehend  how  the  disease  thus  extends  and  is 
disseminated,  we  must  recall  to  mind  that  the  whole  lung  is 


THE   PATHOLOGY   OF   PULMONARY  TUBERCULOSIS        465 

pervaded  in  every  crevice  of  its  structure  by  lymphatic  tissue, 
consisting  of  branched  protoplasmic  cells  communicating  with 
fine  tubes  and  interstitial  spaces  lined  by  endothelial  cells. 
The  late  Sir  John  Burdon  Sanderson  observed  the  sheaths  of 
the  minute  bronchi  as  being  favourite  sites  for  the  origin  of 
such  tuberculous  granulations;  other  common  sites  are  the 
lymphatics  of  the  alveolar  walls,  and  of  the  perivascular  and 
subpleural  tissues. 

We  may  here  observe  that  there  are  two  varieties  of  de- 
generative change  to  which  tuberculous  processes  are  liable, 
and  that  whilst  caseous  necrosis  in  different  degrees  of  in- 
tensity is  the  process  that  especially  awaits  the  inflammatory 
form  of  tuberculosis  of  the  lung,  fibroid  change  is  the  more 
characteristic  sequel  to  the  neoplastic  development  repre- 
sented by  the  firm,  semi-transparent  granulation  which  we  have 
been  describing.  The  peculiar  form  of  fibroid  tissue  into 
which,  under  favourable  circumstances,  tubercle  thus  becomes 
converted  is  at  first  easily  recognisable  from  ordinary  hyper- 
plastic fibrous  tissue.  Subsequently  it  gives  rise  to  bands  or 
tracts  of  uniform  homogeneous  texture.  Finally  it  may  de- 
generate and  be  removed,  leaving  merely  a  pigmented  point 
and  a  more  or  less  tiny  stellate  wrinkle.  This  conversion  of 
tubercle  before  its  final  decay  has,  perhaps,  hardly  been 
sufficiently  insisted  upon  as  an  essential  character  always 
observable,  if  circumstances  permit  the  attainment  of  the 
necessary  stage.  It  is  of  importance  as  affecting  the  clinical 
characters  of  chronic  tuberculosis.  In  acute  tuberculosis  the 
patient  does  not  often  live  long  enough  for  any  process  of 
the  kind  to  take  place.  In  the  chronic  form  of  the  disease, 
however,  and  when  tubercle  attacks  a  lung  rendered  quiescent 
by  prfevious  consolidation,  the  stages  of  development  of 
tubercle  into  fibroid  tissue  may  be  seen. 

(2)  Tuberculous  Pneumonia. — There  is  a  great  difference, 
both  histologically  and  clinically,  between  the  purer  form 
of  tuberculous  lesion,  of  which  we  have  been  hitherto  speak- 
ing, and  those  cases  in  which  the  org-anism  produces  chiefly 
an  inflammatory  process  in  the  pulmonary  tissue.  In  its 
gravest  form  this,  leads  to  a  pneumonic  infiltration  of  the  lung, 
in  coalescing  centres,  inevitably  proceeding  to  caseous  necrosis 
of  the  parts  affected,  a  condition  which  will  be  described  in  a 
succeeding    chapter    under    the    heading    Acute    Pneumonic 


466  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Phthisis.  It  was  long  ago  pointed  out  by  Addison^  that  the 
inflammatory  process  takes  the  largest  and  most  important 
share  in  the  production  of  the  various  appearances  met  with 
in  pulmonary  tuberculosis,  in  which  disease  it  is  the  destroying 
element. 

With  regard  to  the  caseous  necrosis,  it  may  be  stated  that, 
althoug'h  the  fatty  change  which  is  so  important  an  element  in 
the  process  is  common  to  many  inflammations,  and  a  chief 
means  by  which  their  products  become  eliminated  or  absorbed, 
yet  caseation  is  a  more  uniform  result  of  tuberculous  inflam- 
mation than  of  any  other,  and  it  is  almost  synonymous  in  the 
lung  with  the  "crude  or  yellow  tubercle"  of  older  writers. 
The  distinguishing  feature  of  tuberculous  caseation  is  the 
presence  therein  of  the  tubercle  bacillus. 

With  true  lobar  pneumonia  we  have  but  little  to  do  in  deal- 
ing with  cases  of  phthisis;  we  only  meet  with  it  as  an  excep- 
tional complication.  The  form  of  pulmonary  inflammation 
which  is  most  commonly  met  with  is  of  a  different  kind,  and, 
except  in  the  very  acute  forms  already  referred  to,  it  is  more 
insidious  in  onset.  In  form  it  is  broncho-pneumonic,  involving 
the  minute  bronchi  and  infundibula  of  the  lung  over  areas 
of  variable  size  around  each  centre  of  infection.  The  coales- 
cence, however,  of  many  adjacent  foci  may  sometimes  cause 
the  consolidation  of  a  whole  lobe.  Such  inflammation  may  be  - 
due  to  the  tubercle  bacillus  alone,  but  the  action  of  the  bacillus 
is  assisted  in  certain  cases  by  other  organisms,  and  to  this 
matter  we  shall  again  refer. 

Most  commonly  the  cellular  products  of  this  catarrhal  in- 
flammation, after  having  undergone  more  or  less  complete 
caseous  necrosis,  break  down  and  are  eliminated.  Less 
frequently  they  become  inspissated  by  absorption  of  fluid 
matter,  and  remain  for  a  long  time — perhaps  for  the  lifetime 
of  the  patient — in  a  cheesy  condition,  quiescent,  but  a  source 
of  possible  danger  in  that  they  contain  in  many  cases  living 
tubercle  bacilli,  the  activity  of  which  may  be  reawakened 
should  the  patient's  general  vitality  become  lowered  or  the 
local  resistance  in  the  lung  be  diminished  by  intercurrent 
catarrhs  and  congestions.  In  other  cases  calcification  ensues, 
but,  even  in  such  cases,  the  patient  is  by  no  means  always  free 
from  further  risk.- 

In  these  inflammatory  processes  the  elastic  tissue  of  the 


THE  PATHOLOGY  OF  PULMONARY  TUBERCULOSIS        467 

lung  plays  no  active  part.  It  escapes  but  little  altered  when 
the  alveoli  break  down,  and,  when  recognised  in  the  sputum, 
affords  certain  evidence  of  pulmonary  destruction. 

In  addition  to  the  parenchyma  proper  of  the  lung,  which, 
with  its  epithelium,  is  the  special  seat  of  catarrhal  pneumonia, 
there  exists  the  fibrous  stroma,  if  we  may  so  style  it,  formed  by 
the  interlobular  areolar  tissue,  supplying  sheaths  to  the  vessels 
and  bronchi,  contributing  also  to  the  formation  of  the  alveoli, 
and  intimately  connected  at  the  surface  of  the  lung  with  the 
investing  pleura.  It  could  not  be  expected  that  an  inflamma- 
tion of  the  lung  of  any  great  severity  would  leave  this  widely 
spread  tissue  unscathed;  and  it  might  also  be  anticipated  that 
a  tissue  thus,  comparatively  speaking,  deeply  placed  would, 
as  a  general  rule,  only  be  affected  secondarily  to  disease  of 
the  parenchyma  or  pleura.  And  this  we  find  to  be  the  case. 
From  this  interstitial  tissue,  under  conditions  of  inflammatory 
irritation,  are  derived,  in  great  part,  the  tough,  fibrous,  pus- 
secreting  walls  of  cavities,  and  the  trabeculae,  which  for  a  long 
time  resist  the  most  severely  destructive  processes.  The  in- 
flammatory process  in  this  tissue  is  as  a  rule  a  more  de- 
liberate one;  even  when  in  a  state  of  active  ulceration,  as 
in  the  walls  of  certain  cavities,  the  destruction  is  molecular; 
sphacelus  is  rare.  The  inflammatory  reaction,  indeed,  more 
generally  partakes  of  the  character  of  growth  under  irritation, 
producing  fibrosis  of  the  lung,  and  sometimes  this  condition 
may  become  so  extensive  as  to  constitute  the  predominant 
disease.  To  such  cases  the  name  "fibroid  phthisis"  has  been 
appHed.  Decay,  however,  in  most  instances,  finally  sets  in; 
the  fibrous  tissue,  at  first  merely  hyperplastic,  loses  its  char- 
acter as  such ;  its  nuclei,  at  first  abundant,  gradually  fade ;  its 
fibres  fuse  into  tough  homogeneous  bands,  and  in  their 
turn  become  granular  and  fatty,  and  finally  crumble  away. 

(3)  Mixed  and  Secondary  Infections. — We  have  already 
hinted  that,  although  the  tubercle  bacillus  plays  the  specific 
and  predominant  role  in  the  lesions  of  phthisis,  there  are 
other  organisms  to  be  reckoned  with  in  its  pathology,  among 
which  the  streptococcus,  staphylococcus  aureus  and  albus  and 
the  pneumococcus  would  appear  the  more  important.  We 
must  now  consider  what  part  these  play  in  the  evolution  of 
the  disease.  That  such  organisms  are  often  present  in  the 
sputum   of   phthisical   patients,   being   responsible   for    some 


468  DISEASES   OF   THE   LUNGS   AND   PLEURAE 

measure  of  the  bronchial  catarrh,  which  is  so  common  a 
feature  of  the  disease,  and  which  may  be  regarded  in  part  as 
due  to  secondary  infection,  is  a  fact  which  has  long  been  known, 
but  it  is  a  question  much  debated  how  far  they  play  an  active 
role  in  the  spread  of  the  tuberculous  disease.  Certain  ob- 
servers urge  that,  as  fever,  wasting,  caseation  and  softening 
can  all  be  produced  directly  by  the  tubercle  bacillus,  these 
manifestations  of  the  disease  should  be  attributed  to  the 
bacillus,  and  to  it  alone.  The  work  of  Sorgo,^  both  clinical 
and  pathological,  would,  however,  appear  to  show  that  even 
in  sanatorium  patients,  in  whose  sputum  under  the  purer 
atmospheric  conditions  the  bacterial  flora  becomes  markedly 
diminished,  true  mixed  infections,  in  which  the  tuberculous 
granulations  are  the  seat  both  of  tubercle  bacilli  and  other 
infecting  organisms,  do,  though  rarely,  occur.  This  has  been 
confirmed  at  the  King  Edward  VII.  Sanatorium  by  Dr.  J.  A.  D. 
Radcliffe,^  to  whose  Weber-Parkes  Prize  Essay  we  must  refer 
the  reader  for  full  technical  details,  and  for  a  critical  consider- 
ation of  the  hterature  of  this  important  subject.  Dr.  RadcHffe, 
following  Sorgo's  method,  treated  the  sputum  by  repeated 
washings,  and  in  this  way  was  able  to  separate  from  the 
tubercle  bacillus,  by  mechanical  means,  organisms  not  derived 
from  the  actual  focus  of  disease.  He  examined  in  this  way 
the  sputum  of  thirty  patients  suffering  from  febrile  phthisis, 
and  in  twenty-five  he  obtained  a  pure  growth  of  the  tubercle 
bacillus.  In  the  remaining  five  other  organisms  grew  as  well, 
showing  that  they  were  intimately  associated  with  the  tubercle 
bacillus  in  its  activity,  and  these  cases  we  may  regard  as  true 
examples  of  mixed  infection. 

We  may  conclude,  therefore,  that  even  under  sanatorium 
conditions  such  infections  do  occur,  but  only  in  a  small  pro- 
portion of  cases  (though  in  Dr.  Radcliffe's  experience  those 
of  graver  outlook),  and  that  the  activity  of  the  disease  and  its 
febrile  manifestations  are  in  most  instances  the  result  of  the 
unaided  action  of  the  tubercle  bacillus.  That  under  less 
favourable  conditions  mixed  and  secondary  infections  may 
be  of  more  frec[uent  occurrence  is  possible  and  even  likely, 
and  this  view  is  supported  by  the  improved  results  obtained 
by  sanatorium  treatment,  under  the  purer  air  conditions  of 
which  the  opportunities  of  such  infection  are  diminished;  also 
by  the  rapid  spread  of  the  tuberculous  disease,  which  some- 
times results  when  influenza  attacks  a  phthisical  patient. 


THE   PATHOLOGY   OF   PULMONARY  TUBERCULOSIS        469 

(4)  The  Mechanical  Effects  of  the  Rigid  Chest  Wall  and 
Respiratory  Movements. — The  respiratory  movements  of  the 
chest  cavity  take  part  in  the  pathology  of  phthisis,  as  of  other 
thoracic  affections,  but  in  a  more  marked  deg'ree. 

When  the  lung  disease  is  of  a  chonic,  indurative,  contractile 
character,  the  effect  of  the  continued  thoracic  efforts  to  expand 
the  toughened  lung  is  to  stretch  any  adhesions  which  may 
have  formed,  and  to  separate  the  pleural  layers;  the  further 
contraction  of  the  lung-  continues  the  process,  so  that  the 
parietal  and  visceral  pleurae  may  become  separated  by  an  inter- 
val of  as  much  as  half  or  three-quarters  of  an  inch.  This  space 
is  at  first  filled  by  serous  fluid  effused  into  the  loose  meshes 
of  the  areolar  tissue  of  the  stretched  adhesions.  In  this  way 
is  produced  the  oedematous  pleura  (Plate  XXVIII.,  Frontis- 
piece). At  a  subsequent  stage  of  the  disease,  by  the  continued 
gTowth  of  the  areolar  tissue,  the  whole  space  becomes  occu- 
pied by  tough  fibrous  material,  and  the  two  layers  become 
welded  together  into  one  uniform  layer.  That  this  is  the  real 
history  of  the  enormous  thickening  of  the  pleura  in  many 
cases  of  chronic  pulmonary  disease  we  have  satisfied  ourselves 
by  repeated  observation.*  Thickening  of  the  pleura  has  in 
the  past  been  regarded  too  much  in  the  light  of  a  dangerous 
pathological  process,  liable  to  extend  into,  and  by  its  con- 
tractile power  to  compress,  the  proper  lung  tissue.  It  is  gener- 
ally, in  fact,  a  condition  secondary  and  quite  subsidiary  to  the 
lung  disease. 

In  primary  pleuritis  the  thickened  pleura  is  produced  in  a 
different  way.  After  absorption  of  the  fluid,  a  certain  thick- 
ness of  lymph  remains  between  the  two  layers  of  the  pleura, 
into  which  granulations  from  each  surface  penetrate,  and 
finally  unite,  completing  the  adhesion. 

There  are,  however,  not  a  few  cases  of  phthisis  of  the  pneu- 
monic kind  of  tolerably  acute  progress,  and  attended  with 
little  contraction,  in  which,  though  the  pleural  surfaces  are 
inflamed  and  covered  with  finely  granular  lymph,  they  do  not 
become  united.  It  is  in  these  cases  that  pneumothorax  is 
especially  likely  to  occur. 

The  constant  movement  of  the  lungs  no  doubt  goes  far  to 
modify  and  hasten  the  progress  of  morbid  processes  going 
on  within  them,  and  the  constant  access  of  air  to  the  diseased 
surfaces  tends  to  maintain  suppuration  and  to  promote  the 


4/0  DISEASES   OF   THE  LUNGS   AND   PLEURA 

absorption  of  septic  matters.  By  the  inhalation  of  portions  of 
sputa,  laden  with  acrid  and  specific  poison,  to  distant  parts 
of  the  lung-s,  the  lesions  of  phthisis  are  further  disseminated. 

Site  and  Spread  of  the  Lesions. — In  pulmonary  tuberculosis 
of  the  adult  the  disease  usually  manifests  itself  by  a  deposit 
of  tubercle  near  the  apex,  perhaps  more  often  of  the  left 
lung.  From  this  primary  focus  it  extends  downwards  through 
the  lung,  though  before  it  has  proceeded  far  the  opposite  apex 
becomes,  as  a  rule,  affected.  The  march  of  the  disease 
from  apex  to  base  follows  a  more  or  less  definite  progress, 
seen  best  in  chronic  phthisis,  and  which  has  been  carefully 
described  by  Sir  James  Kingston  Fowler.^  Our  own  some- 
what extensive  post-mortem  experience  leads  us  substantially 
to  accept  the  correctness  of  his  conclusions. 

The  first  lesion  is  situated,  not  at  the  extreme  apex  of  the 
lung,  but  about  an  inch  below  its  summit.  From  this  point, 
possibly  as  the  result  of  inhalation  under  the  influence  of 
gravity  in  the  supine  position,  the  disease  spreads  backwards, 
so  that  physical  signs  soon  manifest  themselves  in  the  supra- 
spinous fossa.  Scattered  tubercles  next  make  their  appear- 
ance in  the  front  of  the  upper  lobe,  gradually  extending  down- 
wards from  the  apical  focus.  Before,  however,  such  exten- 
sion has  proceeded  far,  lesions  manifest  themselves  at  the 
apex  of  the  lower  lobe  of  the  same  side,  and  from  this  point 
they  extend,  by  means  of  scattered  areas  of  infiltration,  often 
of  the  nature  of  racemose  tubercle,  towards  the  base.  As, 
however,  Sir  James  Kingston  Fowler  pointed  out,  a  special 
zone  of  infiltration  often  shows  itself  in  the  lower  lobe  along 
the  line  of  the  great  fissure,  so  that  moist  sounds  are  often 
audible  in  this  region  as  far  as  the  anterior  Hmit  of  the  fissure. 

Before  the  disease  has  extended  far  in  the  lung  first 
attacked  the  opposite  apex  becomes  in  most  cases  affected, 
whence  the  disease  progresses  in  a  manner  very  similar  to 
that  already  described  in  the  other  lung.  The  middle  lobe  is, 
in  our  experience,  affected  only  late  in  the  disease,  and  rarely 
to  a  considerable  extent. 

Occasionally  physical  signs  are  most  marked  at  the  base 
of  the  lung,  and  if  they  affect  the  whole  lower  lobe  and  tubercle 
bacilli  are  present  in  the  sputum,  they  may  be  accepted  as 
indicating  tuberculous  disease,  the  case  being  one  of  so-called 
basal  phthisis.     In   such   cases,  which  are   only  of  rare  oc- 


THE  PATHOLOGY  OF   PULMONARY  TUBERCULOSIS        47 1 

ciirrence,  signs  of  an  old  arrested  lesion  at  the  apex  will  not 
uncommonly  be  found. 

Hilum  Tuberculosis. — Recently  another  variety  of  phthisis 
has  been  described,  the  so-called  Hilmn  tuberculosis,  or,  as 
it  is  termed  by  radiologists,  Peribronchial  phthisis,  in  which 
the  disease  is  thought  to  commence  in  the  bronchial  glands 
and  thence  to  spread  fanwise  through  the  lung  along  the 
course  of  the  bronchi  and  vessels. 

In  children  the  bronchial  glands  are  not  infrequently  in- 
fected with  tubercle,  and  may  become  caseous,  a  condition 
which,  as  Professor  Ghon®  and  Dr.  Canti'^  have  shown,  is  in 
most  cases  secondary  to  a  primary  focus  in  the  lung.  The 
attack  may  pass  and  the  lesion  subside  into  obsolescence,  and 
may  so  remain  for  a  long  time,  even  for  life.  In  other  and 
less  common  cases  the  disease  in  the  glands  extends,  spreads 
beyond  the  capsule,  and  directly  invades  the  lung.  Such  cases 
of  pulmonary  tuberculosis  have  long  been  recognised  in 
children. 

In  the  adult  we  believe  that  cases  of  pulmonary  tuberculosis 
originating-  in  the  glands,  if  they  occur,  are  very  rare.  The 
numerous  autopsies  which  we  have  ourselves  performed  in 
cases  of  tuberculosis  have  not  led  us  to  doubt  the  accuracy 
of  the  older  view,  that  in  phthisis  the  disease  in  the  great 
majority  of  cases  commences  near  the  apex,  and  thence,  as  we 
have  already  indicated,  gradually  spreads  downwards  through 
the  lung.  It  is  also  interesting  to  note  that  in  phthisis  in  the 
adult  the  bronchial  glands  are  not,  as  a  rule,  caseous.  In 
263  cases  in  which  we  investigated  this  point,^  we  found  the 
glands  enlarged  in  48-2  per  cent.,  and  showing  areas  of  casea- 
tion in  only  9-1  per  cent.  In  a  further  148  per  cent,  old 
calcareous  foci  were  present.  The  condition,  therefore,  of 
caseation,  in  which  extension  into  the  lung  might  most  reason- 
ably be  expected,  is  not  of  frequent  occurrence.  The  recog- 
nition of  hilum  tuberculosis  is,  in  fact,  largely  based  upon  the 
occurrence  of  shadows  seen  in  screen  examination  and  X-ray 
plates,  which  radiate  into  the  lung  from  the  neighbourhood 
of  the  br'onchial  glands,  which  themselves  often  in  the  adult 
show  evidence  of  old  disease.  Such  radiating  shadows,  in 
the  absence  of  post-mortem  control,  are  notoriously  difficult  to 
interpret,  and  may  have  more  than  one  explanation. 

The  mechanism  of  extension  of  the  infection  from  the  hilum 


472  DISEASES   OF   THE  LUNGS   AND   PLEUK^ 

through  the  substance  of  the  lung  to  its  periphery  is  also 
sornewhat  difficult  to  recognise.  The  supposed  extension  of 
the  infection  is  against  the  current  of  the  lymph  stream, 
though  we  are  aware  that  this  is  not  an  insuperable  objection. 
Arterial  conveyance  of  the  infection  more  usually  assumes 
the  form  of  acute  general  miliary  tuberculosis.  Dr.  Riviere,* 
who  strongly  advocates  hilum  tuberculosis  as  a  separate 
variety  of  the  disease,  would  account  for  the  antecedent 
pleurisies  of  phthisis  by  extension  from  the  hilum  through 
lung  to  pleura;  but  Ave  conceive  their  origin  to  be,  in  the 
particular  cases  referred  to,  more  frecjuently  by  direct  infec- 
tion of  the  pleural  surface  through  the  serous  fluid. 

Our  view,  then,  with  regard  to  hilum  tuberculosis  is  that  it 
is  an  unnecessary  addition  to  nomenclature,  and  we  think 
that  in  the  adult  there  is  reason  to  doubt  the  sound- 
ness of  the  view  that  tuberculosis  spreads  continuously  out- 
wards from  foci  at  the  hilum.  With  other  observers,  we  have 
met  with  cases  in  which,  in  the  absence  of  obvious  lung 
disease,  the  glands  at  the  hilum  have  been  the  seat  of  active 
tuberculous  infection.  Such  cases  have  manifested  them- 
selves by  continued  pyrexia,  and  on  X-ray  examination  the 
hilum  glands  have  been  seen  to  be  considerably  enlarged  and, 
no  doubt,  diseased.  This  variety  constitutes,  in  fact,  a  true 
hilum  tuberculosis,  but  it  is  not  this  form  of  disease  to  which 
the  term  is  usually  applied. 

REFERENCES. 

^  A  Collection  of  the  Published  Writings  of  the  late  Thomas  Addison, 
M.D.,  Physician  to  Guy'' s  Hosfital.  The  New  Sydenham  Society  edition, 
p.  56.     London,   1868. 

"  See  The  Causes  of  Tuberculosis,  by  Louis  Cobbett,  M.D.,  F.R.C.S., 
pp.  71-72.     Cambridge,  1917. 

^  "  Mixed  and  Secondary  Infections  in  Pulmonary  Tuberculosis  "  (the 
Weber-Parkes  Prize  Essay,  1912),  by  J.  A.  D.  Radcliffe,  M.B.,  B.Ch., 
Pathologist,  King  Edward  VII.  Sanatorium,  Midhurst^  Zeitschrift  fiir 
TuberTzulose,  Band  xxi.,  Heft  i,  2  u.  3,  1913. 

*  "  Case  of  Chronic  Tubercular  Disease  of  the  Lungs  illustrating  One 
Mode  of  Production  of  Thickening  of  the  Pleura,"  by  R.  Douglas  Powell, 
M.D.,  Transactions  of  the  Pathological  Society  of  London,  1869,  vol.  xx., 

P-  59- 

*  The  Diseases  of  the  Lungs,  by  James  Kingston  Fowler,  M.A.,  M.D., 
F.R.C.P.,  and  Rickman  John  Godlee,  M.S.,  F.R.C.S.,  p.  350.  London, 
1898.  See  also  The  Localisation  of  the  Lesions  of  Phthisis,  by  J.  Kingston 
Fowler,  M.A.,  M.D.,  F.R.C.P.     London,  i5 


THE  PATHOLOGY  OF  PULMONARY  TUBERCULOSIS        473 

°  The  Primary  Lung  Focus  of  Tuberculosis  in  Children,  by  Dr.  Anton 
Ghon ;  translated  by  D.   Barty  King.     London,   1916. 

"  "  Primary  Pulmonary  Tuberculosis  in  Children,"  by  R.  G.  Canti, 
Quarterly  Journal  of  Medicine,   vol.    xiii..    No.    49,    October,    1919,   p.    71. 

*  Refort  on  the  Work  of  the  Pathological  Defartment  of  the  Bromfton 
Hospital,  Afril^  1900,  to  April,  1903,  by  P.  Horton-Smith  (Hartley),  M.D., 
F.R.C.P.     McCorquodale  and  Co.,  London,  1903. 

«  "  Hilus  Tuberculosis  in  the  Adult,"  by  Clive  Riviere,  M.D.,  F.R.C.P., 
The  Lancet,  1919,  vol.  i.,  p.  213. 


CHAPTER  XXXII 

ON  THE  VARIETIES  OF  PULMONARY  TUBERCULOSIS. 
ACUTE  TUBERCULOSIS  OF  THE  LUNGS 

Laennec  maintained  phthisis  to  be  a  specific  disease,  and  the 
result  of  Koch's  discovery  of  the  tubercle  bacillus  as  the  virus 
in  all  cases  has  been  to  reinstate  his  view.  It  cannot,  how- 
ever, be  questioned  that  the  range  of  pathological  diversity 
within  the  sphere  of  this  single  malady  is  so  great  as  to  justify 
its  subdivision,  for  clinical  purposes  of  prognosis  and  treat- 
ment, into  subgroups  and  varieties.  Without  further  apology, 
then,  we  will  endeavour  to  sketch  the  main  features  of  the 
following  types  of  the  disease  : 

Acute  tuberculosis  of  the  lungs — 

{Acute      pneumonic     phthisis ; 
s\nonyms :    caseous    pneu- 
•"11  f  r 

monia,  lobar  form  of  caseous 
tuberculosis  of  the  lung. 
'Florid  phthisis;  synonyms: 
phthisic  galopante,  broncho- 
pneumonic  caseous  tubercu- 
losis. 
.Acute  miliary  tuberculosis. 


(2)  Disseminated  form 


Subacute  tuberculosis  of  the  lungs — 

Pulmonary  tuberculisation. 

Chronic  tuberculosis  of  the  lungs — 

Chronic     pulmonary     tuberculosis,     ordinary     chronic 

phthisis. 
Fibroid  phthisis. 

There    are    further    to    be    considered    separately,    on    the 
ground  of  mere  convenience,  certain  of  the  prominent  con- 

474 


THE   VARIETIES    OF   PULMONARY   TUBERCULOSIS         475 

sequences  of  phthisis,  about  which  are  grouped  some  of  the 
most  characteristic  features  of  the  disease,  viz. : 

Tuberculous  excavation  of  the  lung — the  cavity  stage 

of  phthisis. 
Haemoptysis. 
Laryngeal  tuberculosis. 

Pneumothorax,  a  sequel  of  more  rare  occurrence,  has  been 
already  fully  dealt  with  in  a  preceding  chapter. 

Acute  Tuberculosis  of  the  Lungs. 

I.  Confluent  Form. 

Acute  pneumonic  phthisis.  Synonyms:  Caseous  pneumonia. 
Lobar  form  of  caseous  tuberculosis. 

In  cases  of  this  type,  the  pathology  of  which  we  have 
described  jn  the  preceding  chapter,  the  consolidation  is  ex- 
tensive and  dense;  the  disease  is  more  "massed"  in  the 
affected  lobe  than  is  the  case  in  the  more  chronic  varieties, 
and  occupies,  perhaps,  its  entire  extent.  As  a  rule  the  initial 
attack  is  one-sided,  and  the  apex  of  the  lung  is  the  part 
affected,  but  in  more  than  one  case  we  have  known  the  base 
first  attacked. 

This  form  of  the  disease  is  apt  to  be  confounded  with 
croupous  pneumonia,  the  signs  of  consolidation  being  uni- 
form over  an  extended  area.  Bronchial  breath-sounds  are  heard, 
and  crepitations,  at  first  fine,  then  coarser,  with  bronchophonic 
voice-sounds.  The  onset  is  abrupt  and  stormy,  with  pain  in 
the  chest,  short  cough,  scanty  expectoration,  sometimes 
attended  with  haemoptysis,  a  raised  temperature,  a  rapid  pulse, 
and  quickened  breathing. 

Many  of  these  massed  consolidations  of  the  lung,  indeed, 
consist  in  part  of  areas  of  simple  pneumonia,  and  it  is  only 
after  the  resolution  of  these  portions  that  the  tuberculous 
nature  of  the  case  is  clinically  unmasked  with  the  softening 
of  those  centres  which  have  undergone  caseation. 

In  the  distinction  of  these  cases  from  the  not  uncommon 
instances  of  true  pneumonia  of  the  apex,  the  following  con- 
siderations are  important : 

(i)  The  temperature,  although  maintained  above  the  normal, 
has  even  from  the  first  a  more  fluctuating  range  than  that  of 


4/6 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


pneumonia.    The  tongue  is  as  a  rule  moister  and  less  coated, 
and  hectic  sweatings  soon  become  marked. 

(2)  No  critical  fall  of  temperature  corresponds  with,  or 
follows  upon,  the  appearance  of  moist  sounds. 

(3)  The  haemoptysis,  if  present,  is  decided,  not  a  mere  rusty 
colouration  of  the  phlegm.  The  sputum  is  also  more  abun- 
dant, and  from  the  first  more  or  less  purulent,  and  soon 
comes  to  contain  bacilH  and  alveolar  elastic  tissue  (Fig.  45). 

(4)  The  leucocyte  count  in  the  blood  is  stated  by  Drs. 
Gulland  and  GoodalP  to  be  usually  below  normal;  in  pneu- 
monia, on  the  contrary,  a  leucocytosis  is,  as  we  have  seen, 
commonly  present. 

IX 


Fig.  45. — Elastic  Tissue  and  Fragment  of  Small  Vessel,  from  Expec- 
toration OF  Patient  with  Rapidly  Forming  Cavities  (drawn  by 
Dr.   Sydney  Coupland). 


X  200. 


(5)  As  the  case  proceeds,  amid  the  moist  crepitant  rales, 
which  cannot  be  distinguished  from  those  of  resolving  pneu- 
monia, larger  clicks  are  heard  in  several  centres,  which  be- 
come more  liquid  and  characteristic  of  pulmonary  softening. 

(6)  The  breath^sound,  which  had  become  more  or  less  com- 
pletely masked  by  the  numerous  rales,  again  appears  in 
patches  corresponding  with  the  large  clicking  rales,  and 
assumes  a  hollow  tubular  quahty.  The  voice-sound  over  these 
areas  becomes  of  a  nasal  snuffling  quality,  and  finally  there  is 
distinct  pectoriloquy. 

(7)  The  rapid  emaciation  and  markedly  hectic  temperature 
of  the  patient,  his  profuse  sweatings,  and  the  increasingly 


THE   VARIETIES   OF  PULMONARY  TUBERCULOSIS         477 

copious  and  purulent  expectoration,  within  a  few  weeks  put 
aside  all  possible  error  of  diagnosis.  Long  before  this,  how- 
ever, the  true  nature  of  the  case  will  have  been  suspected, 
and  the  diagnosis  established  by  the  finding  of  tubercle 
bacilli  after  one  or  more  examinations  of  the  sputum. 

Cases  of  this  form  of  tuberculosis  by  no  means  all  exhibit 
at  the  first  onset  the  stormy  symptoms  above  sketched.  But 
in  all  the  physical  signs  rapidly  extend,  until  a  more  or  less 
considerable  portion  of  one  lung  is  involved,  before  the  signs 
of  breaking  down  into  cavities  are  manifested. 

In  persons  of  "  strumous  "  type,  who  are  common  subjects 
of  this  variety  of  phthisis,  the  fever  may  not  be  sufficiently 
violent,  nor  the  other  symptoms  urgent  enough  to  prostrate 
them  in  bed;  but  remittent  fever,  cough,  expectoration  and 
hectic  sweatings  are  invariably  present,  and  sufficiently  mani- 
fest to  excite  alarrn  in  palrents  and  friends. 

It  is  remarkable,  however,  to  observe  the  rounded  contour 
of  features  and  the  j  relative  plumpness  of  figure  maintained 
by  some  patients  even  far,  on  in  this  form  of  the  malady, 
which  is  certainly  most  Comnion  in  young  girls  and  women. 
The  features  are  usually  pale  with  anaemic  mucous  mem- 
branes, but  in  the  younger  subjects  the  cheeks  may  be  well 
coloured.  The  chest  is  usually  of  fairly  good  formation,  and, 
in  common  with  the  rest  of- ;the  frame,  well  covered  with  a 
layer  of  adipose  tissue.  The  muscular  system  is,  however, 
poorly  developed  and  .languidly  innervated,  the  pulse  feeble, 
and  the  nervous  system  wanting  in  tone. 

In  the  form  of  tuberculosis  now  under  consideration  there 
is,  in  spite  of  its  initial  severity,  not  infrequently  a  tendency 
to  arrest.  This  is  brought  about  by:  (i)  elimination  of  the 
caseous  products;  (2)  cicatricial  contraction  of  the  cavities 
thus  formed;  (3)  compensatory  development  of  the  opposite 
lung. 

It  is  a  mistake  commonly  and  naturally  enough  made  by 
the  inexperienced  observer,  on  having  revealed  to  him 
through  his  stethoscope  the  signs  of  breaking  down  of 
pulmonai-y  consolidation  in  one  or  more  centres,  to  infer  that 
a  further  step  has  been  advanced  towards  a  hopeless  prognosis 
in  the  case  before  him.  In  a  sense,  and  while  fully  admitting 
the  gravity  of  the  case  at  fhe  first  moment  of  diagnosis,  these 
phenomena  of  softening  are  equally  essential  and  important 


4/8 


DISEASES   OF  THE  LUNGS   AND   PLEURAE 


Steps  towards  amendment.  Without  them  it  is  impossible  for 
healing  changes  to  ensue. 

At  the  same  time,  this  process  of  elimination  is  attended 
with  dangers  of  its  own  which  must  be  reckoned  with. 

(a)  Suppurative  fever  necessarily  attends  the  process.  A 
fluctuating  hectic  temperature,  night  sweats,  cough,  and  more 
or  less  profuse  expectoration,  containing  elastic  tissue  and 
bacilli,  are  present.  Haemoptysis  rarely  occurs  to  any  great 
extent.  The  character  of  the  temperature  chart  marking  this 
period  of  phthisis  (Fig.  46)  is  precisely  the  same  as  that  of 
any  imperfectly  drained  abscess,  wherever  situated. 


Fig.  46. — Annie  T.  :  Fluctuating  Hectic  Temperature  ;  Acute  Pneumonic 
Phthisis  ;  Cavities  rapidly  forming. 


(b)  There  is  throughout  this  period  a  danger  of  the  opposite 
lung  becoming  involved  in  separate  centres,  from  inhalation 
of  specific  morbid  products  in  course  of  expectoration.  The 
possibility  of  secondary  miliary  tuberculosis  at  this  stage 
is  also  not  to  be  forgotten,  but  it  is,  so  far  as  we  have  observed, 
a  complication  of  much  more  rare  occurrence  than  in  other 


stages. 


(c)    The    patient    tends    to    become    more    and   more    ex- 
hausted,  and   to   lose  weight   throughout  this   period,   and 


THE   VARIETIES   OF  PULMONARY  TUBERCULOSIS         4;$ 

in  severe  cases  constitutional  resources  are  seriously  taxed 
by  a  downward  course  of  from  six  weeks  to  three  or  four 
months. 

During  the  process  of  elimination  cavities  gradually  become 
manifest  to  auscultation,  and  perhaps  increase  by  coales- 
cence to  form  one  or  two  amphoric  areas.  Some  shrinking 
of  lung  from  loss  of  substance  may  be  observed,  the  heart's 
surface  being  uncovered  more  or  less  to  right  or  left,  accord- 
ing to  the  side  affected. 

Coincidently,  however,  with  these  alarming  signs  of  lung 
destruction,  in  a  goodly  number  of  cases  more  hopeful 
features  may  be  observed,  which  point  towards  the  arrest  of 
the  disease.     Thus : 

(a)  We  may  note  that  the  opposite  lung  has  not  become 
affected  to  any  material  extent,  and  that  the  limits  of  the 
disease  on  the  affected  side  have  not  extended,  but  have 
perhaps  even  retrenched.  It  is  necessary  here  to  warn  the 
auscultator  against  mistaking  morbid  sounds  heard  on  the 
healthy  side,  but  really  consonated  from  the  affected  side,  for 
signs  of  new  disease. 


'to 


(b)  Before  the  subsidence  of  hectic  phenomena,  careful  per- 
cussion and  auscultation  will  reveal  that  the  margin  of  the 
opposite  healthy  lung  is  encroaching  upon  the  sternum  until 
the  whole  sternal  region  is  thus  occupied. 

(c)  The  affected  side  becomes  more  markedly  flattened,  the 
area  of  cardiac  pulsation  more  extended  towards  it,  whilst  the 
cardiac  surface  is  being  covered  by  the  lung  resonance  advanc- 
ing from  the  healthy  side.  The  percussion  note  becomes  duller 
and  more  wooden,  and  the  hollow  breath-sounds  are  less  and 
less  abundantly  accompanied  by  rales.  It  is  to  be  further 
noted,  especially  in  left-sided  cases,  that  the  morbid  pulmonary 
signs  shift  towards  the  upper  axillary  and  infraspinous 
regions.  In  a  word,  the  affected  lung  is  shrinking  towards  its 
root. 

(d)  The  range  of  temperature  gradually  contracts,  and  this 
restriction  may  often  be  observed,  not  only  with  regard  to  the 
high,  but  also  the  low  register,  which  in  the  later  hectic  period 
of  this  disease  is  usually  marked  by  subnormal  points  in 
alternation  with  pyrexial  peaks  (see  Fig.  47).  The  other 
phenomena  of  hectic  abate,  the  patient  regains  appetite  and 
flesh,  and  in  favourable  cases  the  cough  and  expectoration 


480 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


may  cease,  the  cavities  contract,  and  convalescence  become 
fairly  established. 

It  is  to  be  noted  that  throughout  the  period  of  elimination 
and  commencing  cicatricial  change,  tubercle  bacilli  are  to  be 
found  more  or  less  abundantly  in  the  sputum,  which  is 
highly  purulent  and  nummulated.  Nor  can  any  safe  inference 
be  drawn,  favourable  or  otherwise,  in  prognosis,  from  the 
abundance  or  paucity  of  the  organisms,  nor  from  their  char- 
acters. 


Fig.  47. — Hectic  Type  of  Temperature  attending  the  Rapid  Softening 
AND  Elimination  of  Extensive  Caseous  Consolidations.  Lucy  B.  : 
Late  Period  of  Acute  Phthisis. 


In  left-sided  cases,  when  the  lung  has  considerably  con- 
tracted and  all  pulmonary  sig'ns  have  become  quiet,  the  patient 
frequently  complains  of  palpitation  and  occasional  faintness, 
and  ready  disturbance  of  the  heart's  action.  These  symptoms 
are  due  to  the  heart  being  somewhat  displaced,  and  to  the  fact 
that  its  anterior  surface,  unprotected  by  lung,  is  now  in  con- 
tact with  the  depressed  parietes,  while  on  the  left  it  is  further 
bounded  by  thickened  lung  instead  of  its  normal  elastic 
cushion  of  support. 


THE   VARIETIES   OF   PULMONARY   TUBERCULOSIS  48 1 

Illustrative  Cases — Case  I. — As  an  example  of  the  form 
of  disease  which  we  have  been  considering,  we  would  refer  to 
the  interesting  and  instructive  account  of  his  own  case  pub- 
lished in  1901  by  Dr.  R.  Mander  Smyth.-  In  spite  of  the 
severity  of  the  onset  and  the  rapidity  of  its  progress,  the 
disease,  under  appropriate  treatment,  including  a  long  stay  at 
Nordrach,  under  the  care  of  Dr.  Walther,  gradually  became 
arrested.  For  twelve  years  Dr.  Smyth  was  the  head  of  a  well- 
known  sanatorium  in  England,  and  we  are  glad  to  add  that, 
with  one  or  two  temporary  set-backs,  he  has  maintained  his 
health — the  lung  disease,  which  had  proceeded  to  excava- 
tion, remaining  arrested — and  is  at  the  time  of  writing 
(January,  1920)  wintering  near  Mentone.  Latterly  he  has 
been  troubled  with  gouty  manifestations  of  a  chronic  type, 
affecting  chiefly  the  left  shoulder,  and  this  complication  may 
have  exerted  a  not-unfavourable  influence  upon  the  tubercu- 
lous disease.  As  a  personal  experience  of  the  variety  of 
phthisis,  which  we  are  now  discussing,  described  by  a  trained 
medical  observer,  the  account  will  well  repay  perusal. 

The  notes  of  the  two  following  cases  illustrate  further 
points  in  regard  to  this  variety  of  pulmonary  tuberculosis,  and 
appear  worth  recording,  though  we  regret  that  both  terminated 
fatally  after  a  period  of  improvement : 

Case  II. — T.  W.,  aged  thirty-six,  Detective  Sergeant  in  the  City 
Police,  was  admitted  into  the  Brompton  Hospital  under  the  care  of 
Dr.  Hartley  on  November  28,  1914. 

He  came  of  healthy  stock,  and  there  was  no  history  of  tuberculosis  in 
his  family.  He  had  suffered  from  dyspepsia  for  some  years,  but  had 
otherwise  enjoyed  good  health.  Since  July,  19 14,  however,  he  had 
been  feeling  "  run  down,"  had  latterly  had  a  little  cough,  and  in 
October  on  two  occasions  coughed  up  a  small  clot  of  blood.  He 
continued  at  his  work,  but  on  November  9,  when  on  duty  in  connection 
with  the  Lord  Mayor's  procession,  he  felt  so  unwell  that  he  was 
obliged  to  leave  his  post  and  rest  for  awhile.  Next  day  he  felt  chilled, 
but  managed  to  continue  his  work  until  November  12,  when  he  was 
admitted  to  the  City  Police  Hospital,  complaining  of  shivering  and 
pains  in  his  joints.  He  was  found  to  have  a  temperature  of  101°,  and 
a  few  days  later  signs  of  consolidation  were  detected  in  the  right  upper 
lobe,  and  on  NQvember  18  tubercle  bacilli  were  found  in  the  sputum. 
On  November  28  he  was  transferred  to  the  Brompton  Hospital.  His 
early  temperature  record,  commencing  on  the  fourth  day  of  his  acute 
illness,  was  courteously  supplied  by  the  authorities  of  the  City  Police 

31 


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Fig.  48. — CH.4RT   SHOWING  THE  TEMPERATURE   RECORD   OF   T.   W.,    DETECTIVE 

Sergeant,   aged   Thirty-six,   who   suffered  from   Acute  Pneumonic 
Phthisis. 


THE   VARIETIES   OF   PULMONARY   TUBERCULOSIS  483 

Hospital,  and  is  shown  in  the  annexed  chart  (Fig.  48).     It  will  be  seen 
to  be  continuously  raised,  but  of  somewhat  remittent  type. 

On  admission  to  Brompton  on  the  twentieth  day  of  his  acute  illness 
his  temperature  was  102-6°,  pulse  88,  respiration  28.  His  height  was 
5  feet  io|  inches,  but  owing  to  his  condition  he  could  not  be  weighed  on 
admission.  There  was,  however,  no  history  of  loss  of  weight.  Some 
night-sweating  was  observed,  and  his  sputum  was  muco-purulent  in 
character  and  contained  tubercle  bacilli.  In  the  right  lung  there  were 
no  physical  signs  of  disease,  but  in  the  left  lung  an  area  of  consolida- 
tion was  present,  as  shown  by  impaired  note,  bronchial  breath-sound, 
and  bronchophony,  extending  from  the  third  to  the  sixth  rib  in  front. 
Over  this  area  consonating  rales  were  audible.  Posteriorly  the  note 
was  impaired  from  the  apex  of  the  left  lung  to  the  angle  of  the 
scapula,  and  moist  sounds  were  heard  over  this  region. 

The  patient  was  placed  upon  absolute  rest,  but  the  temperature 
remained  irregularly  raised  for  the  next  week,  and  then  became  lower, 
but  for  many  weeks  it  oscillated  between  99°  and  100°,  and  it  was  not 
until  the  middle  of  February,  1915,  that  it  became  normal  (see 
Fig.  48).  The  physical  signs  did  not  alter  materially  for  a  consider- 
able time.  On  December  16  friction  was  audible  in  the  left  axilla,  but 
on  December  30  it  had  disappeared.  By  the  middle  of  February  the 
signs  of  consolidation  had  diminished,  the  note  over  the  left  front 
was  less  impaired,  and  bronchial  breath-sound  was  only  audible  at 
times.  There  were  still,  however,  moist  sounds  over  the  front  of  the 
left  lung,  extending  to  above  the  clavicle.  Posteriorly  the  signs  were 
much  as  on  admission,  impairment  of  note  with  moist  sounds  being 
present  over  the  upper  half  of  the  left  lung.  The  cough  was  now 
slight  and  the  sputum  scanty,  but  tubercle  bacilli  were  still  present. 

During  January  and  February  he  was  treated  with  increasing  doses 
of  creosote  up  to  a  maximum  of  25  minims  twice  a  day  in  two  drachms 
of  cod-liver  oil.  From  January  15  to  January  22  and  from  February  12 
to  24  he  received  also  a  daily  subcutaneous  injection  of  sodium 
cacodylate  gr.  |. 

The  case  had  now  taken  a  more  favourable  turn,  and  hopes  of 
recovery  were  entertained.  On  March  22,  however,  he  had  a  serious 
haemoptysis,  bringing  up  a  pint  of  blood,  followed  by  a  rise  of 
temperature  to  104°.  The  pyrexia  lasted  for  a  fortnight,  and  the 
temperature  then  remained  irregularly  raised  for  some  weeks,  and  it 
was  not  until  the  early  part  of  May  that  it  again  became  normal.  The 
signs  in  the  lungs  had  now  increased,  moist  sounds  being  audible  at 
the  left  base  and  also  over  the  right  middle  lobe  and  the  adjacent  part 
of  the  upper  lobe.  The  note  at  the  right  apex  was  also  now  impaired. 
His  weight,  which  before  the  haemoptysis  had  risen  to  11  stone 
7  pounds,  had  now  fallen  to  10  stone  7  pounds. 

In  this  condition  he  remained  till  June  30,  when  he  was  transferred 
to  the  Brompton  Hospital  at  Frimley  in  the  hope  of  further  improve- 
ment. His  temperature,  however,  soon  rose  again.  He  was  confined 
to  bed,  suffered  a  good  deal  from  dyspepsia,  lost  weight,  and  left  for 


484  DISEASES    OF   THE   LUNGS   AND   PLEURA 

his  home  near  Shrewsbury  on  September  30,  where  he  died  a  few  weeks 
later  in  November,  1915,  just  a  year  after  the  commencement  of  his 
acute  illness.  It  is  possible  that  but  for  the  haemoptysis  the  improve- 
ment previously  noted  might  have  been  maintained. 

Case  III. — Mrs.  X.,  aged  twenty-nine,  married,  but  without 
children,  was  first  seen  by  Dr.  Hartley  in  October,  igii,  in  consultation 
with  Dr.  Rose  of  New  Barnet. 

There  had  been  no  history  of  tuberculous  trouble  in  her  family,  but 
she  herself  had  never  been  robust,  and  six  years  previously  her  left 
kidney  had  been  removed  for  tuberculous  disease,  with  secondary 
involvement  of  the  bladder.  The  operation  was  successful,  and  she  lost 
her  symptoms  and  regained  her  health,  remaining  well  until  June,  191 1, 
when  she  began  to  suffer  from  cough,  with  some  muco-purulent  expec- 
toration. She  did  not  think  she  was  losing  weight.  Her  height  was 
5  feet  3  inches ;  weight  8  stone  125  pounds.  There  were  no  sweats  or 
haemoptysis,  ^n  physical  examination  the  percussion  note  at  both 
apices  was  found  to  be  impaired  ;  some  rhonchi  were  audible  over  the 
lungs,  but  no  added  sounds  were  heard  at  the  apices.  There  appeared 
to  be  no  fever,  and  the  sputum  on  two  examinations  did  not  reveal 
tubercle  bacilli.  A  diagnosis  of  bronchial  catarrh  with  arrested  tuber- 
culous lesions  at  the  apices  was  made,  and  under  treatment  by  expec- 
torant mixtures  and  cod-liver  oil  she  soon  recovered  her  health,  losing 
cough  and  phlegm  and  gaining  in  weight. 

She  remained  well  until  March  2,  1915,  when  she  contracted 
influenza  complicated  by  bronchitis.  The  sputum  was  scanty  and 
purulent,  and  contained  mostly  pneumococci.  Tubercle  bacilli,  though 
searched  for  on  two  occasions,  were  not  found.  On  March  14,  1915, 
she  was  seen  at  Hadley  Wood  by  Dr.  Hartley,  in  consultation  with 
Dr.  Evill,  who  was  attending  her  in  the  absence  of  Dr.  Rose  on  war 
service.  Her  temperature  was  still  raised  and  of  intermittent  type, 
varying  from  98°  in  the  morning  to  101°  at  night.  The  tongue  was 
furred,  there  was  some  sweating,  and  the  impairment  of  note  observed 
in  191 1  was  still  manifest  at  the  apex  of  the  right  lung;  the  note  at 
the  left  apex  was  now  fairly  natural.  Signs  of  general  bronchitis  were 
audible  over  the  lungs,  and  at  the  left  base  there  was  obvious  impair- 
ment of  note,  with  bronchial  breath-sound  and  sticky  rales.  A  diag- 
nosis of  influenzal  pneumonia  was  made,  and  as  Mrs.  X.  was  holding 
her  own,  a  hopeful  prognosis  was  given.  The  temperature,  however, 
as  may  be  seen  from  the  "  average  chart  "  (Fig.  49),  which  dates  from 
the  third  day  of  her  illness,  did  not  fall,  and  was  of  a  somewhat  hectic 
type,  and  bronchial  breath-sounds  still  remained  audible  below  the 
angle  of  the  left  scapula.  The  question  of  a  vaccine  was  considered, 
and  for  this  purpose  the  sputum  was  examined  by  the  late  Dr.  Stans- 
feld,  who  found  no  tubercle  bacilli  or  influenza  bacilli,  but  a  bac- 
terial flora  among  which  streptococci  now  largely  predominated.  A 
streptococcal  vaccine  was  prepared  and  three  doses  given  without 
effect. 


THE   VARIETIES   OF   PULMONARY  TUBERCULOSIS 


485 


On  April  17  the  patient  was  again  seen  in  consultation  with  Sir 
Thomas  Horder  and  Dr.  Evill.  Her  temperature  still  remained  raised 
to  over  101°  at  night,  and  her  cough  was  irritable.  The  tongue,  how- 
ever, was  clean  and  the  patient  looked  fairly  well.  There  were  still  a 
few  signs  of  general  bronchial  catarrh,  but  the  note  at  the  right  base 
showed  now  only  slight  impairment.  At  this  base,  however,  many 
crepitations  were  audible  after  coughing.  The  patient's  appearance, 
general  condition,  and  the  continuing  pyrexia  strongly  suggested 
tubercle,  and  it  was  decided  that  a  further  examination  of  the  sputum 
should  be  made,  and  on  this  occasion  tubercle  bacilli  were  discovered 
by  Dr.  Stansfeld  in  considerable  numbers.  The  case,  therefore,  was 
now  proved  to  be  one  of  arrested  tuberculosis  of  the  apices,  with  a 


Fig.  49. — "  Average  Chart  "  showing  the  Weekly  Temperature  Record 
OF  Mrs.  X,  aged  Twenty-nine^  who  suffered  from  Acute  Pneumonic 
Phthisis. 

(The  record  is  obtained  by  taking  the  average  of  the  morning  and  also  of 
the  evening  temperatures  during  each  week.) 

recent  acute  invasion  of  the  base  of  the  left  lung  under  the  influence 
of  an  influenzal  attack. 

The  patient  was  placed  en  absolute  rest  and  treated  on  full  open-air 
lines,  and  on  April  21  was  moved  to  a  shelter  built  for  her  in  the 
garden.  From  May  4  to  May  20,  June  3  to  12,  and  from  June  23  to 
29,  she  was  given  a  daily  subcutaneous  injection  of  sodium  caco- 
dylate,  gr.  |,  but  the  pyrexia  still  continued,  though  on  a  somewhat 
lower  level. 

On  June  29  Mrs.  X.  was  seen  again  in  consultation  with  Dr.  Evill. 


486        "         DISEASES   OF  THE  LUNGS  AND   PLEURAE 

By  now  the  disease  in  the  left  lung  had  spread,  and  it  was  clear  that 
the  whole  lung  was  involved,  impairment  of  note  and  scattered 
crepitations  being  audible  all  over.  The  right  lung  was  free  from 
disease,  except  for  the  apical  impairment  of  old  standing.  The  cough 
was  troublesome,  the  sputum  purulent,  and  the  fingers  showed  slight 
clubbing.  The  patient  was  placed  on  intensive  iodine  treatment,  being 
given  20  grs.  of  iodide  of  potassium  at  8  a.m.,  and  an  ounce  of  chlorine 
water  in  freshly  prepared  lemonade  at  12,  2  and  4  p.m.  Under  this 
treatment  the  fever  gradually  abated  and  the  temperature  reached 
normal  on  August  17,  having  been  raised  for  four  and  a  half  months. 

On  October  23,  the  temperature  still  remaining  normal,  the  patient 
was  moved  to  the  Linford  Sanatorium  in  the  New  Forest,  and  placed 
under  the  care  of  Dr.  Felkin.  Here,  after  a  short  stay,  the  temperature 
again  began  to  rise  and  the  cough  and  sputum  increased.  The  case 
still  appeared  one-sided,  and  it  was  decided  to  attempt  an  artificial 
pneumothorax ;  but  though  six  punctures  were  made,  the  attempt 
failed  owing  to  the  presence  of  widespread  pleural  adhesions. 

On  January  25,  1916,  Mrs.  X.  was  seen  in  consultation  with 
Dr.  Felkin.  She  was  evidently  much  weaker,  with  hectic  flush  on  the 
cheeks  and  a  temperature  of  101°.  The  pulse  was  rapid  and  soft,  the 
sputum  considerable  in  amount  and  containing  tubercle  bacilli  in  large 
numbers.  A  cavity,  extending  from  the  left  clavicle  to  the  fifth  rib, 
was  present  in  the  upper  lobe,  and  there  was  a  second  excavation  at 
the  apex  of  the  lower  lobe  behind.  The  upper  half  of  the  right  lung 
was  also  now  invaded  by  active  tuberculous  disease.  Under  the  cir- 
cumstances it  was  obvious  that  no  operative  procedure  could  be  con- 
sidered, and  that  the  patient's  condition  was  one  of  great  gravity. 
Garlic  was  prescribed  without  avail,  and  the  patient  died  a  few  weeks 
later,  just  a  year  from  the  commencement  of  her  illness. 

This  case  illustrates  the  temporary  improvement  vv^hich  may- 
be observed  in  cases  of  this  kind,  and  then  the  active  extension 
of  the  disease  in  the  other  lung,  which  sometimes  takes  place 
and  carries  off  the  patient,  even  though  the  surroundings  are 
all  that  can  be  desired.  The  failure  to  effect  an  artificial 
pneumothorax,  owing  to  the  presence  of  extensive  pleural 
adhesions,  will  also  be  noticed. 

The  supervention  of  caseo-pneumonic  tuberculosis,  running 
a  rapid  course,  was  formerly  not  infrequent  in  diabetes.  The 
statistics  brought  forward  in  1883  at  a  discussion  on  diabetes 
at  the  Pathological  Society^  showed  that  about  35  per  cent. 
of  the  cases  terminated  in  pulmonary  tuberculosis,  most 
commonly  in  the  second  to  the  fourth  years  of  the  disease, 
and  that  in  a  still  larger  proportion — nearly  one-half — pul- 
monary lesions  were  present.  In  the  present  day,  when  the 
death-rate  from  phthisis  is  about  half  what  it  was  in  1883,  such 


THE   VARIETIES   OF  PULMONAJRY  TUBERCULOSIS         487 

figures  are  too  high,  nor  does  the  compHcation,  in  our 
experience,  now  run  as  a  rule  such  a  rapid  course  in  diabetic 
patients.  Nevertheless,  the  possibility  of  the  development  of 
pulmonary  tuberculosis  must  always  be  borne  in  mind  when 
treating  a  case  of  diabetes,  since  in  this  disease  the  vitality 
of  the  tissues  is  lowered,  and  the  patient  becomes  more 
prone  to  invasion  by  the  tubercle  bacillus.  The  lesions  are 
more  apt  also  to  occur  in  situations  other  than  apical,  the  base 
of  the  lung  being  not  uncommonly  attacked. 

All  pulmonary  lesions  in  diabetes  are  not,  however,  tuber- 
culous. In  some  having  clinical  features  suggestive  of 
phthisis,  tubercle  bacilli  are  not  found,  and  the  destructive 
lesion  is  a  species  of  sloughing  pneumonia. 

2.  Disseminated  Form. 

(i)  Florid  Phthisis.  Synony^ns :  Phthisie  Galopante. 
Broncho-Pneumonic  variety  of  Caseous  Tuberculosis. 

In  other  cases,  of  happily  rare  occurrence,  acute  tubercu- 
losis attacks  both  lungs,  commencing  simultaneously  in  many 
centres.  This  form  of  the  disease,  which  is  most  common  in 
young  adults,  and  perhaps  more  frequent  in  women  than  in 
men,  bears  the  same  relationship  to^  the  preceding  variety  that 
disseminated  bears  to  confluent  broncho-pneumonia,  and  is 
characterised  by  the  rapid  softening  of  the  caseous  foci  and  by 
marked  destruction  of  lung  texture. 

The  symptoms  are  not  essentially  different  from  those  of 
the  more  ordinary  confluent  form  of  acute  phthisis  which  we 
have  just  described,  but  the  dyspnoea  is  more  urgent,  and  the 
progress  to  a  fatal  issue  rapid,  and  as  a  rule  unbroken.  The 
flushed  face,  bright  eyes,  and  alert  mind  contrast  with  the 
apathy,  pallor,  and  prostration  of  acute  miHary  tuberculosis, 
and  the  physical  signs  at  first  of  acute  bronchial  catarrh  with 
the  rapid  development  of  numerous  centres  of  consolidation, 
softening,  and  excavation,  are  equally  characteristic.  The 
rapid  breaking  down  of  the  broncho-pneumonic  centres, 
occurring  first  at  the  apices,  is  a  striking*  feature,  distinguish- 
ing this  from  more  simple  forms  of  broncho-pneumonia. 

After  death  the  lungs  are  found  to  present  numerous  areas 
of  greyish-pink  granular  consoHdation,  with  yellow  caseous 
centres  broken  down  into  small  cavities  communicating 
widely  with  enlarged,  more  or  less  eroded,  and  acutely  in- 


488  DISEASES   OF  THE  LUNGS   AND  PLEURA 

.flamed  bronchial  tubes.  No  miliary  granulations  of  tubercle 
are  to  be  seen,  although  the  smaller  yellow  centres  may  at  first 
sight  resemble  them. 

Except  on  grounds  of  clinical  accuracy,  the  distinction 
between  acute  disseminated  phthisis  and  acute  miliary  tuber- 
culosis is  of  little  importance,  for  the  prognosis  in  both  is 
about  equally  fatal  within  a  short  period  of  from  four  weeks 
to  two  or  three  months. 

The  high  and  fluctuating  temperature,  hectic  sweatings, 
purulent,  sometimes  blood-stained,  and  soon  nummulated 
sputa  containing  elastic  tissue  and  bacilli,  in  association  with 
the  physical  signs,  will  render  it  impossible,  except  in  the 
earliest  stage,  to  confound  this  disease  with  acute  bronchitis. 
In  some  cases,  as  in  other  varieties  of  rapidly  progressing 
pulmonary  tubercle,  the  temperature  assumes  the  inverse  type 
with  evening  instead  of  morning  remissions. 

An  inquiry  into  the  family  history  of  a  case  of  acute  dis- 
seminated phthisis  will  frequently  elicit  evidence  of  a  decided 
phthisical  taint. 

The  following  sketches  illustrate  the  phenomena  character- 
istic of  this  form  of  the  disease  : 

Case  I. — A  woman  aged  thirU'-one  had  had  "  inflammation  of  the 
lung's  "  two  years  previously,  but  had  sufl^ered  from  more  or  less  cough, 
with  frothy  expectoration,  for  three  years.  She  knew  of  no  family 
predisposition  to  phthisis.  Four  weeks  before  admission  into  hospital 
she  expectorated  a  small  quantity,  two  teaspoonfuls,  of  blood,  and  the 
sputa  continued  to  be  tinged  for  five  days.  She  had  since  suffered  from 
night-sweats,  emaciation,  cough,  and  pain  in  the  side  and  between  the 
shoulders,  of  which  symptoms  she  complained  on  admission.  The 
pulse  was  112;  the  tongue  furred;  catamenia  regular.  The  physical 
signs  on  admission  were  harshness  at  the  right  apex,  with  subcrepitant 
rales ;  at  the  left,  jerking  breath-sound  with  prolonged  expiration.  She 
decreased  rapidly  in  weight,  losing  3^  pounds  between  October  26  and 
November  14. 

On  November  8  the  physical  signs  were  noted  as  unchanged.  On 
the  2ist  she  was  much  worse,  had  a  red,  tremulous  tongue,  a  rapid 
pulse,  great  breathlessness,  and  much  heat  of  skin.  She  could  with 
difficulty  stand  from  the  trembling  of  her  limbs  and  weakness.  Sub- 
crepitant rales  were  found  diffused  throughout  the  right  side  behind, 
with  some  defect  in  resonance  not  amounting  to  dulness.  The 
temperature  taken  night  and  morning  from  this  date  showed  a 
maximum  morning  height  of  103°,  avei  ge  ioi-6°;  maximum  evening 
temperature  104°,  average  102-3° ;  difference  between  the  average 
morning  and  evening  temperature  0-7°.     On   the  frequent  occasions 


THE   VARIETIES   OF  PULMONARY  TUBERCULOSIS         489 

when  observed  in  the  middle  of  the  day,  the  skin  was  uniformly  hot, 
and  the  pulse  very  rapid,  usually  about  120.  Meanwhile  the  pulmonary 
physical  signs  advanced,  the  crepitations  became  more  abundant,  and 
extended  through  both  lungs.  There  were  signs  of  breaking  down  at 
the  right  apex,  though  the  presence  of  a  cavity  could  not  be  ascertained 
with  certainty.  On  December  19  there  were  present  "  diffused  blowing 
respiration,  with  sonorous  rhonchus  and  scattered  crepitations,  more 
abundant  at  the  bases,  with  some  dulness  ;  high  temperature,  and  much 
dyspnoia."  On  December  15  the  patient  began  to  be  troubled  with 
diarrhoea,  which  continued  more  or  less  to  the  last.  The  emaciation 
and  loss  of  power  rapidly  increased,  the  smooth  red  tongue  became 
white  with  aphthous  patches,  and  she  gradually  sank,  having  never 
evinced,  however,  any  delirium  or  other  morbid  brain  symptoms. 

Post-mortem,  the  lungs  were  found  studded  with  racemose  groups  of 
tubercle  undergoing  caseation  and  softening,  and  surrounded  by  ill- 
defined  areas  of  pneumonia  ;  the  right  apex  was  breaking  up  into  small 
cavities.    There  was  no  miliary  tubercle  on  the  pleural  surfaces. 

The  continued  fever,  the  great  and  early  prostration,  the 
presence  of  physical  signs  at  the  apex,  and  later  of  diffused 
crepitations  over  the  lungs,  without  any  defined  dulness, 
rendered  the  diagnosis  of  pulmonary  tuberculosis  being  the 
prevaiHng  lesion  a  tolerably  certain  one;  but  the  case  was 
differentiated  from  one  of  acute  mihary  tuberculosis  by  the 
early  presence  of  marked  pulmonary  signs  and  a  less  degree 
of  general  prostration  than  often  accompanies  the  latter 
disease,  which  is  also  attended  by  muttering  delirium.  There 
was,  however,  but  little  satisfaction  to  be  derived  from  this 
reflection,  for  the  prognosis  was,  so  far  as  present  knowledge 
could  decide,  inevitably  fatal. 

Case  II. — W.  A.,  van-boy,  aged  sixteen,  was  admitted  into  the 
Brompton  Hospital  under  the  care  of  one  of  us  on  August  18,  1913, 
complaining  of  cough,  expectoration,  and  night-sweating. 

There  was  no  history  of  tuberculosis  in  his  family,  and  he  stated 
that  he  himself  had  been  quite  well  until  three  months  previously,  when 
he  began  to  suffer  from  cough. 

On  admission  he  was  found  to  be  febrile,  having  a  morning 
temperature  of  ioo-8°,  which  rose  in  the  evening  to  102-2°.  His  cough 
was  troublesome,  especially  at  night,  and  a  good  deal  of  yellow  phlegm 
was  expectorated,  in  which  tubercle  bacilli  were  discovered.  The 
bowels  were  regular.  The  physical  signs  in  the  chest  indicated  invasion 
of  the  whole  of  the  right  lung,  as  shown  by  diminished  mobility  and 
general  impairment  of  note,  with  scattered  crepitations.  Signs  of 
excavation  were  also  present  below  the  clavicle.  On  the  left  side  the 
percussion  note  was  impaired  from  the  apex  to  the  third  rib  in  front 


490 


DISEASES   OF    THE  LUNGS   AND   PLEURA 


Fig.   50.— Temperature  Chart  of  W.  A.,  Van-Boy,  aged   Sixteen,   who 

SUFFERED    FROM    ACUTE    CaSEOUS    TUBERCULOSIS    OF    THE    BRONCHO-PNEU- 
MONIC   TYPE. 


THE   VARIETIES   OF   PULMONARY   TUBERCULOSIS  49 1 

and  over  the  upper  third  of  the  lung  posteriorly,  and  over  these  areas 
sharp  crepitations  were  audible. 

After  admission  the  pyrexia  continued,  the  temperature,  as  shown  in 
the  annexed  chart  (Fig.  50),  being  of  the  high  remittent  type.  The 
patient  complained  of  some  pain  in  the  right  side,  but  otherwise 
suffered  little.  His  cough  continued  and  he  grew  weaker.  His  pulse 
and  respiration  increased  in  rapidity,  the  former  on  September  ig 
being  136,  the  latter  44.  Meanwhile  the  signs  of  excavation  in  the 
right  lung  were  extending,  and  on  September  19  a  large  thin-walled 
cavity,  involving  the  whole  of  the  apical  portion  of  the  lung  and 
yielding  a  bell  sound,  was  observed.  A  few  days  later  he  became 
cyanosed  and  dyspnoeic,  and  some  oedema  of  the  feet  appeared.  The 
pyrexia  continued. 

On  September  26  physical  signs  of  pneumothorax  of  the  right  side 
were  observed,  its  onset  being  probably  indicated  by  a  sudden  fall  in 
the  temperature  on  September  22.  On  October  3  the  pneumothorax 
had  become  practically  complete,  as  indicated  by  a  tympanitic  note, 
bell  sound  and  loud  amphoric  breathing  heard  over  the  right  side  of 
the  chest.  The  loudness  of  the  amphoric  breath-sound  suggested 
that  the  opening  into  the  pleural  cavity  was  large  and  patent,  and 
such  the  autopsy  proved  to  be  the  case.  In  addition  to  the  air  some 
fluid  was  also  now  present  in  the  pleural  cavity,  as  revealed  by  the 
succussion  splash  and  movable  dulness. 

The  temperature  remained  raised  until  October  i,  when  with 
increasing  weakness  it  fell  gradually  to  normal.  The  patient  was  now 
very  dyspnoeic  and  cyanotic  at  times,  and  died  on  October  6. 

At  the  autopsy  a  pyopneumothorax  was  found  occupying  the  right 
side  of  the  chest,  with  the  exception  of  its  apical  portion,  where  the 
pleurae  were  adherent.  The  right  upper  lobe  contained  a  large  excava- 
tion, which  communicated  with  the  pleural  cavity  by  a  hole  situated  in 
the  lower  and  anterior  portion  of  the  lobe,  the  size  of  a  threepenny 
piece,  and  having  thickened  edges.  Besides  air  the  pleura  contained 
20  ounces  of  pus.  In  addition  to  the  large  cavity  present  in  the  right 
upper  lobe,  a  second  excavation  of  considerable  size  and  containing 
much  purulent  material  was  found  in  the  left  upper  lobe.  The  right 
middle  and  lower  lobes  were  thickly  studded  with  coalescing  areas 
of  caseous  broncho-pneumonia,  and  in  the  left  lower  lobe  similar, 
though  less  extensive,  changes  were  observed.  The  larynx  showed 
ulceration  of  the  right  vocal  cord,  and  the  trachea  was  extensively 
ulcerated.     The  bronchial  glands  were  enlarged  and  caseous. 

The  case  is  an  interesting  one,  as  showing  the  rapid  pro- 
gress to  a  fatal  termination  w^hich  marks  this  variety  of 
pulmonary  tuberculosis — in  this  instance  the  duration  being 
four  and  a  half  months.  The  ulceration  of  larynx  and  the 
occurrence  of  pneumothorax  should  also  be  noticed,  since,  as 
we  have  pointed  out  elsewhere/  these  complications  are  rather 


492  DISEASES   OF  THE  LUNGS   AND   PLEURA 

more  common  in  the  acute  variety  of  the  disease  now  under 
consideration  than  in  ordinary  chronic  phthisis. 

(2)  Acute  Miliary  Tuberculosis. 

The  following  case  of  miliary  tuberculosis,  the  clinical 
features  of  which  we  will  sketch,  will  serve  to  emphasise  the 
-  fact  that  the  tuberculous  lesions  of  this  variety  of  the  disease 
run  their  course  to  a  fatal  issue  with  little  or  no  softening, 
and  also  to  illustrate  the  close  clinical  resemblance  which  may 
exist  between  some  cases  of  acute  miliary  tuberculosis  and 
typhoid  fever : 

Case  I. — Elizabeth  G ,  aged  thirty-four,  a  pale,  sallow,  grave- 
featured  woman,  with  slight  malar  flush,  was  admitted  into  the  Mid- 
dlesex Hospital  in  March,  1885,  complaining  of  cough  and  increasing 
weakness,  with  some  pain  of  a  pleuritic  character  in  the  left  side,  with 
which  she  had  been  troubled  for  three  months.  For  a  week  she  had 
been  confined  to  bed  with  headache,  cough,  and  some  oedema  of  the 
feet. 

On  examination,  only  a  few  scattered  bronchitic  rales  were  dis- 
covered in  the  chest,  the  splenic  dulness  was  increased,  and  the 
abdomen  was  observed  to  be  full  and  tympanitic.  The  pulse  was  100, 
small,  feeble,  regular ;  respirations  18 ;  temperature  102-4°.  The 
tongue  was  red  and  raw  looking,  and  coated  in  the  centre  with  a  thin 
fur.  No  spots  of  a  tj^phoid  character  were  found  on  the  abdomen,  but 
numerous  sudamina  were  observed  scattered  over  the  chest  and 
abdomen. 

The  temperature  ranged  above  100°,  daily  reaching  102°,  and 
frequently  103°,  but  was  kept  more  or  less  modified  by  antipyrine, 
administered  whenever  it  rose  above  102°. 

Up  to  April  20  no  further  chest  signs  were  observed ;  there  was  then 
noted  slight  dulness  and  crackle  after  cough  over  the  right  sub- 
clavicular region,  and  some  superficial  crepitant  rales  at  the  angle  of 
the  right  scapula.  Diarrhoea  was  not  present,  but  the  abdomen  con- 
tinued prominent  and  tympanitic,  and  there  was  some  tenderness  on 
pressure,  especially  over  the  splenic  region. 

On  April  25  the  spleen  was  felt  to  extend  below  the  costal  cartilages. 
On  May  7  there  were  signs  of  a  little  fluid  in  the  peritoneum,  and 
palpation  of  the  abdomen  gave  a  sense  of  soft  resistance,  as  though 
from  matting  together  of  intestines  by  adhesions.  Obscure  crepitation 
was  heard  below  the  second  cartilage  on  the  right  side,  becoming  more 
manifest  and  moister  at  the  anterior  base.  On  the  left  side  some 
crepitations  were  heard  in  the  mammary  region.  There  were  sub- 
crepitant  rales  at  both  posterior  bases. 

The  cough  was  troublesome,  expectoration  scanty  and  viscid.  The 
sputum  was  carefully  examined  on  several  occasions  without  discover- 


THE   VARIETIES   OF   PULMONARY   TUBERCULOSIS  493 

ing  any  tubercle  bacilli.  No  diarrhoea  was  at  any  time  present.  The 
oedema  of  the  legs  increased,  and  the  patient  lapsed  into  a  semi- 
conscious state,  her  temperature  moderating  somewhat,  but  keeping 
above  the  normal. 

In  this  condition  she  lingered,  until  death  ensued  on  June  30,  three 
months  after  her  admission. 

The  post-mortem  examination  revealed  miliary  tuberculosis  of  lungs, 
pleurae,  spleen,  kidneys  and  peritoneum,  with  adhesive  peritonitis. 
There  was  a  small  nodule  of  old  disease  at  the  apex  of  the  right  lung. 
None  of  the  tubercles  had  softened.  This  patient's  sister  had  ten  years 
previously  died  of  rapid  phthisis. 

Some  of  those  who  observed  this  case  from  time  to  time 
were  doubtful  as  to  whether  it  was  one  of  enteric  fever  or 
tuberculosis.  The  continued  fever,  swollen  abdomen,  en- 
larged spleen  and  marked  adynamia,  were  certainly  suggestive 
of  enteric  fever,  nor  from  experience  could  it  be  said  that 
the  absence  of  diarrhoea,  was  sufficient  to  negative  such  a  diag- 
nosis. In  both  diseases,  too,  the  leucocyte  count  in  the  blood 
is  diminished.  At  the  period  at  which  this  case  was  observed, 
the  aid  of  Widal's  test  was  not  available.  The  temperature, 
however,  although  maintained  at  a  high  level,  was  of  too  fluc- 
tuating a  type  to  correspond  with  the  assumed  period  of 
typhoid.  Moreover,  the  hectic  flush  is  rarely,  if  ever,  seen, 
and  sweatings  of  sufficient  severity  to  produce  sudamina  are, 
in  our  experience,  equally  uncommon  in  early  typhoid.  The 
pulmonary  signs  were  at  first  quite  compatible  with  either 
disease.  As  time  went  on  it  was  apparent  that  an  adhesive 
peritonitis  with  slight  effusion  was  present,  and  the  further 
development  of  chest  signs  rendered  the  diagnosis  secure. 

Cases  are,  on  the  other  hand,  sometimes  met  with  in  which 
the  catarrhal  pulmonary  signs  in  the  early  weeks  of  enteric 
fever  mislead  to  a  diagnosis  of  acute  tuberculosis,  a  mistake 
which,  by  preventing  the  strictness  of  dietary  suitable  for  the 
former  disease,  may  seriously  hazard  recovery.  Enlargement 
of  the  spleen  is  an  important  sign  in  favour  of  enteric  fever, 
since  tuberculous  disease  of  the  spleen,  although  present  in 
the  case  related  above,  is  not  usual.  Later  on  in  enteric  fever 
the  pulmonary  signs  fade,  whilst  the  enteric  phenomena  be- 
come more  marked. 

It  is  to  be  observed  that  in  the  case  which  we  have  recorded, 
as  in  others  of  the  same  type,  a  careful  examination  of  the 
expectoration  for  bacilli  on  several  occasions  gave  a  negative 


494  DISEASES  OF  THE  LUNGS   AND  PLEURA 

result,  a  failure  depending  upon  the  absence  of  softening  of 
the  miliary  tubercles  in  the  lung.  Occasionally,  however,  they 
may  be  found,  as  in  an  interesting  case  under  the  care  of  one 
of  us,  in  which,  though  nineteen  successive  examinations  of 
the  sputum  by  Dr.  Wethered  proved  negative,  bacilli  were  yet 
found  by  him  on  the  twentieth  occasion,  to  disappear  again  on 
the  twenty-first.  On  the  death  of  the  patient  soon  afterwards 
the  lungs  were  found  studded  with  miliary  tubercles. 

It  is  instructive  to  observe  that  the  post-mortem  examina- 
tion of  E.  G.  revealed  some  old-standing  mischief  at  the  apex 
of  the  right  lung.  Miliary  tuberculosis  is  in  truth  a  secondary 
disease,  there  having  been  most  commonly  in  adult  cases  a 
previous  abortive  attack  of  phthisis,  and  when  this  is  not  so, 
some  caseous  remmant  of  a  tuberculous  lesion  will  be  found 
elsewhere  in  the  body.  In  children  the  primary  focus  is  more 
often  a  caseous  bronchial  gland. 

The  following  case  is  an  example  of  that  variety  of  the 
malady  in  which  the  pulmonary  signs  are  more  prominent : 

Case  II. — Mrs.  L.  D.,  housewife,  aged  twenty-eight,  was  admitted 
into  the  Brompton  Hospital  under  the  care  of  one  of  us  on 
June  lo,  1918,  with  the  following  history.  She  came  of  a 
healthy  family,  no  members  of  which  were  known  to  have 
died  of  tuberculosis,  and  she  had  herself  always  been  strong 
and  well  until  the  previous  March,  when  she  had  a  miscarriage. 
This  was  followed  by  abdominal  pain  in  the  right  and  left  iliac  regions, 
which  did  not,  however,  persist.  In  April  she  began  to  be  troubled  by 
cough,  with  some  phlegm,  and  this  was  followed  by  nausea,  failing 
appetite,  night-sweats  and  wasting.  Since  May  13  she  had  attended 
the  Out-Patient  Department  at  the  Brompton  Hospital,  and  on  May  21 
tubercle  bacilli  were  found  in  the  sputum.  For  the  twelve  days  pre- 
ceding her  admission  to  the  hospital  she  had  again  complained  of  pain 
in  the  right  iliac  fossa,  made  worse  by  any  movement. 

On  admission  on  June  10  she  was  found  to  be  much  emaciated. 
Height  5  feet  4  inches ;  weight  6  stone  13I  pounds.  She  was  flushed 
and  breathless;  temperature  10 1- 6°;  pulse  124;  respiration  32.  Her 
cough  was  very  troublesome  and  persistent,  and  at  times  she  suffered 
from  distressing  paroxysms  of  coughing,  but  sputum  was  absent 
or  very  scanty.  Three  days  after  admission  a  small  quantity  was 
obtained,  and  in  it  tubercle  bacilli  were  again  discovered. 

The  physical  signs  were  interesting.  The  percussion  note  over  the 
upper  part  of  each  lung,  both  anteriorly  and  posteriorly,  was  impaired, 
and  moist  sounds  were  audible  over  the  upper  and  middle  lobes 
anteriorly  and  down  to  the  angle  of  the  scapula  behind.  One  or  two 
rales  were  also  heard  over  the  base  of  the  left  lung.     Pain  and  tender- 


THE   VARIETIES   OF   PULMONARY   TUBERCULOSIS 


495 


ness  on  palpation  were  present  in  the  right  iliac  fossa.  A  vaginal 
examination  showed  nothing  abnormal.  In  view  of  the  physical  signs, 
and  also  the  finding  on  two  occasions  of  tubercle  bacilli  in  the  scanty 
sputum,  which,  as  we  have  seen,  is  rare  in  miliary  tuberculosis,  the 
diagnosis  of  acute  caseous  tuberculosis  of  the  broncho-pneumonic  type, 
rather  than  miliary  tuberculosis,  was  made,  a  point,  however,  of 
academic  rather  than  practical  interest,  in  view  of  the  grave  nature  of 
the  prognosis  in  either  case.  The  abdominal  pain  was  thought  to 
point  to  a  possible  appendicitis  of  tuberculous  origin. 

After  admission  the  pyrexia  continued,  and,  as  shown  in  the  chart 
(Fig.  51),  was  of  the  continuous  type  with  some  remissions.      There 


Fig.    51. — Chart    showing   the   Temperature   Record    of    Mrs.    L.    D., 
AGED  Twenty-eight,  who  suffered  from  Acute  Miliary  Tuberculosis 

AFFECTING   THE   LUNGS   AND    OtHER   OrGANS. 


was  disinclination  for  food  and  some  vomiting,  but  the  abdominal  pain 
gradually  disappeared.  On  June  26  the  patient,  who  was  now  very 
breathless  and  much  weaker,  complained  of  pain  in  the  right  side  of 
the  chest,  and  friction  was  detected  over  the  lower  and  anterior  part 
of  the  right  lung.  A  few  days  later  the  heart  showed  signs  of  dilatation. 
On  July  3  the  friction  had  disappeared,  but  fine  crepitations  were  now 
heard  over  the  whole  chest,  both  back  and  front,  pointing  to  general 
involvement  of  the  lungs.  On  July  6  the  patient  passed  into  a  semi- 
conscious condition,  the  pulse  became  feeble,  and  she  died  the 
same  day.    - 

At   the  autopsy   both    lungs    were   found   riddled   throughout    with 
miliary  tubercles,  yellowish  in  colour.    Some  recent  pleurisy  was  visible 


496  DISEASES    OF   THE  LUNGS   AND   PLEURA 

in  the  lower  part  of  the  right  lung  in  front,  accounting  for  the  friction 
sounds  heard  during  life.  Miliary  tubercles  were  present  in  the  spleen, 
and  in  the  peritoneum  in  the  region  of  the  caecum,  duodenum,  and 
liver,  with  some  peritonitis,  thus  explaining  the  abdominal  symptoms 
which  had  been  obser\'ed.  There  was  no  ulceration  of  the  intestines 
or  the  appendix,  and  no  focus  of  old  disease  could  be  discovered  in  the 
lungs.  The  bronchial  and  mediastinal  glands  were  enlarged  and 
caseous. 

The  duration  of  the  disease  in  this  case  would  appear  to 
have  been  about  three  months.  xA,s  no  focus  of  old  disease 
could  be  found  in  the  lungs,  it  is  probable  that  some  of  the 
larger  caseating  miliary  tubercles  softened  and  broke  down, 
thus  accounting  for  the  presence  of  tubercle  bacilli  in  the 
sputum  during  Hfe.  The  blood-infection  which  caused  the 
terminal  miliary  tuberculosis  would  appear  to  have  originated 
in  one  of  the  caseating  bronchial  or  mediastinal  glands. 

The  treatment  of  acute  tuberculosis  of  the  lungs,  as  of  the 
other  varieties  of  phthisis,  will  be  fully  considered  in  later 
chapters,  when  the  question  of  prophylaxis  is  also  discussed. 

REFERENCES. 

'  The  Blood:  a  Guide  to  its  Examination  and  to  the  Diagnosis  and 
Treatment  of  its  Diseases,  by  G.  Lovell  Gulland,  M.D.,  and  Alexander 
Goodall,  M.D.,  p.  287.     Edinburgh,  1914. 

^  "  A  Personal  Experience  of  Galloping  Consumption,"  by  R.  Mander 
Smyth,  M.D.,  The  Practitioner ,  1901,  vol.  Ixvii.,  p.  36. 

^  "  Discussion  upon  the  Morbid  Anatomy  of  Diabetes,"  Transactions 
of  the  Pathological  Society  of  London,  1883,  vol.  xxxiv.,  p.  328. 

*  Re-port  071  the  Work  of  the  Pathological  Defart?nent  of  the  Bromfton 
Hosfital  during  the  Three  Y ears  Afril,  1900,  to  Afril,  1903,  by  P.  Horton- 
Smith  (Hartley),  M.D.,  F.R.C.P.,  p.  20.  McCorquadale  and  Co.,  Ltd., 
London,  1903. 


CHAPTER  XXXIII 

ON   SUBACUTE  TUBERCULOSIS  OF   THE  LUNGS 

In  a  certain  not  large  proportion  of  cases  of  pulmonary  tuber- 
culosis the  disease,  instead  of  assuming  the  acute  and  rapid 
confluent  or  disseminated  forms  above  described,  follows  a 
more  insidious  course,  in  which  the  destructive  changes  are 
effected  by  a  drier  and  more  gradual  necrosis.  In  these  cases 
great  thickening  of  the  alveoli,  grey  induration,  in  which  some 
individual  granules  of  tubercle  may  or  may  not  be  distinguish- 
able by  the  unaided  eye,  is  substituted  for  the  more  usual  and 
rapidly  caseating  tuberculous  process,  although  some  points 
of  caseation  may  here  and  there  be  observed.  We  have,  in 
fact,  a  local  pulmonary  tuberculisation  of  slower  and  more 
insidiously  destructive  progress  than  caseous  pneumonia,  so 
far  as  the  lung  is  concerned,  but  more  obstinately  and  con- 
tinuously invasive;  more  prone  to  be  succeeded  by  early  im- 
plication of  the  other  lung,  supposing  both  are  not  from  the 
first  affected;  more  quickly  followed  by  disease  in  other 
organs,  particularly  the  larynx  and  intestines;  and,  in  short, 
though  a  subacute  or  chronic  disease,  yet  one  of  more  early 
average  termination  than  the  corresponding  pneumonic  form 
of  phthisis.  To  this  form  of  the  disease  we  have  in  our  former 
editions  given  the  name  of  pulmonary  tuberculisation.  The 
condition  is  one  intermediate  between  acute  and  chronic  tuber- 
culosis of  the  lung,  and  having  some  special  features  of  its 
own.'^' 

This  form  of  tuberculosis  spreads  through  the  lung  from 
apex  to  base,  with  a  well-defined  grey  advancing  margin,  to 
which  the  hig'hly  vascular  but  crepitant  lung  tissue  immedi- 
ately beyond  presents  a  striking-  contrast.     On  examining, 

*  A  good  illustration  of  this  condition,  of  lung  will  be  found  in  Wilson 
Fox's  Atlas  of  the  Pathological  Anatomy  of  the  Lungs,  Plate  XVII.,  Fig.  i  ; 
but  the  figure  is  reversed,  the  disease  being  apical. 

497  32 


498  DISEASES   OF  THE  LUNGS   AND   PLEURA 

however,  more  minutely  with  a  lens,  the  alveolar  walls  are 
found  considerably  thickened  to  some  little  distance  (perhaps 
half  an  inch)  beyond  the  defined  margin,  though  the  alveolar 
spaces  are  not  occupied  with  catarrhal  cells — at  least,  not  uni- 
formly so  or  to  any  material  extent.  A  few  outlying  patches 
or  nodules  may  often  be  observed,  evidently  of  infective 
origin.  The  aspect  and  insidiously  invasive  character  of  the 
lesion  most  resembles  lupus  of  the  cutaneous  surface;  and 
since  this  comparison  was  first  made  in  the  1878  edition  of 
this  work,  lupus  has  been  shown  to  be  a  truly  tuberculous 
affection. 

The  following  may  be  stated  as  the  clinical  features  most 
distinctive  of  this  form  of  phthisis,  which  is  especially  im- 
portant from  the  difficulties  attendant  upon  its  early  recogni- 
tion, and  on  account  of  its  relentless,  although  gradual, 
course. 

The  origin  and  progress  of  the  disease  are  peculiarly 
insidious,  with  gradually  increasing-  malaise  and  anaemia, 
nocturnal  cough,  and  irregular  fever.  In  many  cases  the 
temperature  is  persistently  though  shghtly  raised.  In  others 
it  is  at  times  elevated,  during  which  periods  there  are  fresh 
accessions  of  disease.  The  non-febrile  intervals  are  of  vary- 
ing duration,  the  fever  in  this  respect  presenting  no  important 
difference  from  that  which  is  observed  in  the  more  ordinary 
forms  of  phthisis,  except  that  the  completely  apyr^xial  intervals 
are  more  rare  and  of  shorter  duration. 

The  physical  signs  are  more  characteristic.  Instead  of 
catarrhal  signs  proceeding  to  well-marked  dulness  and  coarse 
crepitation  or  crackling,  we  find  a  continued  weakness  of 
respiratory  murmur,  with  impaired  expansion  or  actual  flatten- 
ing, while  moist  sounds  may  be  altogether  absent,  or  a  few 
crackles  may  alone  be  elicited  on  cough.  The  percussion  note 
becomes  hardened,  and  we  may  be  surprised  by  the  appear- 
ance (having  omitted  to  examine  the  patient  for  a  week  or 
two)  of  some  feeble,  blowing  respiration,  of  hollow  quality, 
still  very  dry,  which  increases  in  the  same  obscure  way  until 
an  unmistakable  cavity  is  present.  This  formation  of  a  cavity 
by  a  process  of  dry  necrosis  is  characteristic  of  pulmonary 
tuberculisation. 

Huskiness  of  voice,  or  actual  aphonia,  is  commonly  one  of 
the  early  symptoms  in  this  variety  of  consumption.    The  huski- 


ON   SUBACUTE  TUBERCULOSIS   OF  THE  LUNGS  499 

ness  may  clear  off,  but  the  voice  remains  more  or  less  per- 
manently altered  in  quality.  Too  hasty  a  diagnosis  must  not, 
however,  be  made  from  this  symptom,  lest  a  grave  prognosis 
be  founded  upon  a  simple  laryngeal  catarrh,  although  in  many 
cases  the  larynx  is  actually  involved.  The  digestive  organs 
are  as  a  rule  affected  early.  The  tongue  may  present  a  scanty 
white  fur  on  a  very  red  ground,  with  prominent  red  papilla, 
an  appearance  which  is  significant  of  intestinal  lesion,  and 
still  more  so  if  the  fur  clears  off  in  patches,  leaving  raw- 
looking  glazed  surfaces.  Soon  the  symptoms  characteristic 
of  this  lesion — alternating  diarrhoea  and  constipation,  with 
colicky  pains,  especially  after  food — make  their  appearance. 

Patients  who  are  the  subject  of  this  form  of  tuberculosis 
are  usually  of  slender  figures  and  good  features,  and  among 
them  are  those  more  interesting  examples  of  consumption  or 
decline  that  novelists  prefer  to  describe.*  This  variety  is, 
however,  amongst  the  more  rare  forms  of  phthisis. 

The  physical  signs  steadily,  although,  as  already  said,  in- 
sidiously progress,  and  the  average  duration  may  be  pretty 
safely  reckoned  as  within  two  years  of  the  first  appearance  of 
definite  signs,  although  exceptional  cases  last  longer,  and  it 
may  be  hoped  that  more  may  do  so  under  modern  methods 
of  treatment.  The  intestinal  or  laryngeal  complications  cause 
great  distress  towards  the  last,  and  hasten  the  fatal  termina- 
tion. 

The  following  case,  which  was  seen  by  one  of  us  in 
consultation  at  Harlesden,  may  be  sketched  as  an  example 
coming  within  the  category  of  this  variety  of  consumption  : 

Miss  W ,  aged  nineteen,  a  typist,  had  been  losing  flesh  for  three 

or  four  months,  with  increasing  weakness,  which  obliged  her  to 
relinquish  business  eight  weeks  ago.  There  was  a  history  of  an  acute 
abdominal  illness  three  years  previously,  with  symptoms  attributed  to 
colitis,  from  which,  however,  she  quite  recovered.  The  only  symptom 
complained  of  in  her  present  illness,  except  the  weakness  and  the  loss 
of  flesh,  was  relaxation  of  the  bowels,  which  had  been  fairly  constant, 
but  kept  in  check  by  bismuth  and  occasional  opiate  medicines.  The 
doctor  stated  that  "  the  temperature  had  never  been  above  the  normal." 
The  pulse  had,  however,  always  been  notably  quickened,  100  to  120. 
There  had  not  been  any  cough  beyond  an  occasional  clearing  of  the 
throat  in  the  morning,  nor  any  expectoration.     The  catamenia  had 

*  We   may    perhaps    recall    as    examples    Paul    Dombey    and    "  Smike " 
among  Dickens's  characters^  and  Marguerite  Gautier  of  Dumas. 


500  DISEASES   OF  THE  LUNGS  AND   PLEURA 

been  absent  for  twelve  months.  The  girl's  aspect — her  delicate 
features  and  complexion,  with  large  lustrous  eyes,  long  eyelashes, 
slight  hectic  flush,  and  notable  emaciation — presented  the  features  of 
what  was  formerly  described  as  "decline  "  in  medical  literature  and 
in  fiction.  There  had  never  been  any  haemoptysis.  The  stools  had 
not  been  observed  to  contain  mucus,  nor  to  present  any  soapy,  fatty, 
or  other  special  appearances. 

At  the  time  of  consultation — about  4  p.m.  on  December  16,  1910 — 
the  temperature  taken  for  several  minutes  in  the  mouth  was  found  to 
be  99'4°,  and,  on  further  questioning,  the  doctor  who,  owing  to  the 
patient's  small  means,  had  not  had  the  advantage  of  a  nurse  to  observe 
this  symptom  closely,  admitted  an  occasional  temperature  of  99°  or  a 
little  higher — a  temperature  often,  but  erroneously,  regarded  as  "  about 
normal."  The  pulse  was  quick  and  small ;  the  abdomen  was  retracted, 
and  over  an  area  of  some  4  square  inches  below  the  margin  of  the  liver 
there  was  some  tenderness  on  palpation,  with  slight  resistance  as 
compared  with  the  left  side,  and  impaired  resonance  on  percussion. 
The  margins  of  this  resisting  area  were  irregular  and  not  sharply 
defined,  and  it  was  regarded  as  due  to  matted  intestines  and  omental 
thickening.  Neither  liver  nor  spleen  was  enlarged.  There  was  no 
swelling  over  the  pancreas,  no  thickening  or  tenderness  over  the 
caecum. 

The  thorax  was  small  and  the  muscles  wasted,  and  over  an  area  in 
the  left  anterior  axillary  region,  commencing  at  the  outer  third  of  the 
second  rib  in  front,  and  extending  downwards  outside  the  nipple  line  to 
the  level  of  the  fourth  rib,  and  backward  to  the  mid-scapular  line,  the 
percussion  note  was  dull.  Over  this  region  the  respiratory  murmur 
was  weak  and  of  a  muffled  bronchial  quality,  which  in  the  mid-area 
became  markedly  cavernous,  although  still  feeble;  the  voice-sounds  and 
whisper  here  were  pectoriloquous.  But  few  rales  were  heard,  only  two 
or  three  coarse  crackles.  Elsewhere  over  the  lungs  on  both  sides  the 
note  was  resonant  and  the  breath-sounds  weak  but  vesicular. 

With  great  difficulty  a  small  sample  of  sputum  was  obtained,  watery 
in  character,  with  a  few  opaque  shreds.  This  was  carefully  examined 
before  and  after  treatment  with  antiformin,  but  no  tubercle  bacilli  were 
discovered. 

In  its  peculiar  insidiotisness,  in  the  obscurity  of  develop- 
ment of  physical  signs,  and  their  notable  dryness  even  until 
so  near  the  end,  and  in  the  absence  of  associated  catarrhal 
sounds  and  symptoms,  this  case  is  fairly  typical  of  the  form 
of  tuberculosis  now  under  consideration.  So  obscure  were 
the  signs  and  symptoms  that,  whilst  one  physician  had  a  short 
time  previously  expressed  the  view  that  the  lung  was  involved, 
two  others  had  regarded  the  case  as  one  of  disease  of  the 
pancreas.  There  could  be  no  doubt,  however,  from  the 
present  physical  signs,  as  to  the  case  being  one  of  pulmonary 


ON   SUBACUTE  TUBERCULOSIS   OF  THE  LUNGS  501 

and  abdominal  tuberculosis,  the  lung  being  the  seat  of  grey 
indurating  tuberculisation,  with  dry  necrosis,  resulting  in  ex- 
cavation at  the  centre,  the  site  of  the  lesion  being,  however, 
somewhat  unusual.  The  abdominal  lesion  presented  the 
features  of  an  intestinal  matting,  with  tuberculous  ulceration 
of  the  mucous  membrane  of  the  coils.  It  was  obvious  that 
a  fatal  termination  mig'ht  be  expected  within  a  few  weeks. 

At  a  second  consultation,  on  December  31,  the  patient  was  notably 
weaker,  the  area  of  pulmonary  consolidation  had  extended,  and  a  few 
more  liquid  rales  could  be  heard.  She  had  had  an  acute  attack  of  pain 
in  the  upper  right  abdominal  region,  and  the  tenderness  here  was 
more  marked.  The  tongue  was  red,  smooth,  with  some  aphthous 
points.  Some  sputum  was  again  obtained  with  difficulty ;  it  was  of 
mucoid,  frothy  character,  and  on  examination  tubercle  bacilli  in  fair 
numbers  were  found  irregularly  distributed  through  it.  The  patient 
died  on  January  11,   191 1. 

There  are  two  points  to  be  noted  further  in  this  case.  In 
all  probability  the  temperature  on  more  accurate  observation 
would  have  been  found  to  present  a  daily  rise  to  99°  or  100°. 
No  doubt,  too,  the  abdominal  complication,  as  usual,  helped 
to  obscure  the  chest  signs ;  but  involvement  of  other  organs, 
whether  of  larynx  or  intestine,  is  a  specially  common  feature 
in  this  variety  of  phthisis. 


CHAPTER  XXXIV 

CHRONIC  TUBERCULOSIS  OF  THE  LUNGS 

The  subject  of  this  form  of  tuberculosis  has  usually  been 
depressed  in  health,  through  tardy  convalescence  from  some 
other  disease,  bad  living,  mental  anxiety,  or  overwork;  he  has 
had  a  persistent,  though  it  may  be  a  slight,  cough  for  a  longer 
or  shorter  time,  and  has  been  losing-  weight.  Pyrexia  is  one 
of  the  earliest  and  most  important  signs  that  the  pulmonary 
trouble  is  more  than  that  of  a  mere  catarrh,  and  haemoptysis, 
however  slight— even,  it  may  be,  only  a  mere  streak  in  the 
morning  sputum— is  of  serious  significance.  The  pyrexia 
may  not  amount  to  more  than  a  slight  evening  rise  of  tempera- 
ture, but  it  is  attended  with  malaise  and  increased  cough  at 
night. 

At  this  stage  the  physical  signs  are  but  slight.  The  percus- 
sion note  at  one  apex  is  slightly  impaired,  with  perhaps  some 
diminution  in  the  width  of  the  normal  isthmus  of  resonance 
above  the  clavicle  (Kronig^s  sign).  The  respiration  is  also 
weaker,  and  the  inspiration  wavy,  or  even  jerking.  There  are 
usually  a  few  rhonchi  present,  which,  if  limited  to  that  apex,  are 
very  significant ;  and,  ini  addition,  there  is  heard  at  the  extreme 
summit  of  the  lung  (supraclavicular  or  supraspinous  region) 
a  peculiar  crumpling  sound  at  the  moment  of  cough,  which 
differs  both  in  time  and  degree  from  the  crepitant  sound 
audible  at  a  somewhat  later  stage  with  the  first  inspiration 
following  a  cough. 

These  physical  signs — and  their  early  recognition  is  of  much 
importance — are  those  of  a  broncho-alveolar  catarrh  limited 
to  one  apex.  Such  an  apical  catarrh  is  not  necessarily  tuber- 
culous in  nature,  but  should  always  be  regarded  with  the 
gravest  suspicion,  and  when  taken  in  conjunction  with 
symptoms  of  emaciation,  quick  pulse,  and  evening  pyrexia, 
affords  strong  evidence  of  early  tuberculous  disease. 

An  immediate  examination  of  the  sputum  for  tubercle  bacilli 

502 


CHRONIC   TUBERCULOSIS    OF   THE   LUNGS  503 

is  now  imperative,  and,  if  negative,  should  be  repeated  on 
at  least  two  occasions,  and  with  the  help  of  concentration 
methods  (p.  574).  The  importance  of  such  an  early  and 
thorough  examination  of  the  sputum,  and  especially  of  that 
portion  coughed  up  on  first  waking-,  in  all  cases  in  which  there 
is  the  slig'htest  suspicion  of  tubercle  cannot  be  too  strongly 
emphasised,  for,  as  we  shall  see,  our  chance  of  arresting  the 
disease  varies  to  a  great  degree  with  the  stage  at  which  it  is 
recognised,  and  proper  treatment  commenced.  Too  much 
stress  also  must  not  be  laid  upon  a  negative  result,  in  the 
presence  of  the  symptoms  mentioned,  unless  the  sputum  has 
been  examined  on  several  occasions.  In  this  connection  we 
may  refer  again  to  the  case  of  miliary  tuberculosis  of  the  lungs 
which  we  have  already  described,  in  which,  with  simple  stain- 
ing, tubercle  bacilli  were  first  found  in  the  sputum  on  the 
twentieth  examination.  In  children  and  others  who  swallow 
their  expectoration,  it  is  sometimes  possible  to  discover  the 
bacilli  in  the  stools  (p.  574). 

In  the  early  stages  of  phthisis  a  blood-examination  shows, 
as  a  rule,  some  degree  of  anaemia,  the  red  corpuscles  being- 
diminished  and  the  colour  index  lowered,  though  not  to  the 
degree  met  with  in  chlorosis.  Leucopenia  is  usually  also 
present,  the  diminution  in  the  number  of  leucocytes  affecting 
chiefly  the  polymorphs,  so  that  a  relative  increase  of  the  lym- 
phocytes occurs.  As  the  disease  progresses,  and  cavitation  and 
hectic  ensue,  a  leucocytosis  is  often  observed,  possibly  reach- 
ing 20,000  or  more,  the  polymorphs  becoming  increased.  In 
the  opinion  of  some  observers  a  total  increase  of  the  lym- 
phocytes is  at  this  stage  a  hopeful  element  in  prognosis. 

Arneth  has  drawn  attention  to  a  change  in  the  blood  pic- 
ture occurring  in  phthisis,  as  well  as  in  other  infectious 
diseases,  and  which  is  indicated  by  an  increase  in  the  blood 
in  the  number  of  neutrophile  leucocytes  containing  one  or 
two  subdivisions  of  the  nucleus,  and  a  diminution  of  those 
with  three  or  more.  This  change  occurs  early  in  phthisis, 
and  tends,  though  with  some  curious  exceptions,  to  become 
more  marked  as  the  disease  advances  and  to  lessen  as  the 
patient's  condition  improves.  As  Dr.  H.  A.  Treadgold' 
shows  in  his  interesting  paper,  in  which  he  gives  the  results 
of  his  observations  at  the  Brompton  Hospital,  further  investi- 
gation is  required  before  we  can  decide  upon  the  value  of 


504  DISEASES   OF   THE  LUNGS   AND   PLEURA 

the  Arneth  count  in  the  diagnosis  and  prognosis  of  pul- 
monary tuberculosis,  but  for  the  present  we  may  accept  that 
while  the  persistent  presence  of  the  Arneth  blood-picture  in 
marked  degree  would  indicate  a  serious  condition  of  the 
patient,  its  absence  does  not  necessarily  "warrant  a  good 
prognosis. 

In  the  acute  stages  of  phthisis  the  systemic  blood-pres- 
sure is  commonly  lowered,^  ranging  often  between  90  and 
100  mm.  Hg.  This  is  mainly  attributable  to  depressed  car- 
diac function  from  excessive  absorption  of  tuberculous 
toxine,  a  similar  lowering  of  blood-pressure  having  been 
noticed  after  a  suitable  injection  of  old  tuberculin.  When 
the  disease  becomes  chronic  and  quiescent  a  recovery  to 
normal  systemic  pressure  may  often  be  observed,  and  is  of 
good  augury  in  prognosis.  We  may  add  that  a  raised  blood- 
pressure  is  no  bar  to  infection,  and  we  have  known  cases 
of  arterio-sclerosis  with  high  blood-pressure  develope  chronic 
pulmonary  tuberculosis. 

The  disease  tends  insidiously  to  progress.  The  malaise, 
anaemia,  nocturnal  cough,  and  irregular  fever  increase,  the 
physical  signs,  at  first  so  obscure  at  one  apex,  gradually 
advance,  and  the  other  lung  rarely  escapes  involvement.  In  a 
certain  proportion  of  cases,  probably  larger  than  is  generally 
supposed,  the  larynx  becomes  affected. 

So  far  as  the  pyrexia  is  concerned,  there  is  nothing-  char- 
acteristic to  describe.  During  periods  of  activity  the  tempera- 
ture is  elevated,  reaching,  it  may  be,  100°  or  101°  at  night,  and 
falling  to  normal  in  the  morning.  Possibly  also  for  a  few  days 
it  may  take  on  the  inverse  type,  the  morning-  record  being 
higher  than  the  evening;  but,  as  we  have  already  pointed  out 
(p.  488),  this  as  a  rule  occurs  only  in  the  rapidly  progressing 
forms  of  the  disease.  The  non-febrile  intervals  are  of  varying 
and  sometimes  of  long  duration. 

The  main  features  of  an  average  case  of  this  form  of  con- 
sum.ption,  its  physical  signs,  and  some  of  its  aetiological  and 
other  factors  that  have  a  bearing  upon  prognosis,  are  illus- 
trated in  the  following  sketch.  It  will  be  observed  that  the 
patient  comes  under  observation,  not  at  the  commencement, 
but,  as  such  cases  so  often  do  in  practice,  at  a  fairly  pro- 
nounced although  still  comparatively  early  stage  of  the 
disease. 


CHRONIC   TUBERCULOSIS   OF   THE  LUNGS  505 

A  tall,  thin,  worn,  anemic  woman,  aged  twenty-nine,  came  to  the 
hospital  for  advice  on  account  of  lung  symptoms.  She  was  suckling  a 
child  seven  weeks  old,  with  which  she  had  become  pregnant  eleven 
months  after  the  birth  of  twins,  and  whilst  still  suckling  the  survivor 
of  them.  Since  her  last  confinement  she  had  been  suffering  from 
increasing  debility,  shortness  of  breath,  loss  of  flesh  and  cough,  with 
yellow  expectoration,  recently  tinged  with  blood.  There  were  also 
occasional  night-sweatings.  Her  chest  was  narrow  and  somewhat 
flattened,  with  deficient  general  mobility,  but  without  any  local 
depression  or  restraint  of  movement.  The  resonance  at  the  left  apex 
was  impaired,  the  respiratory  sounds  there  being  harsh  and  wanting 
in  vesicularity,  and  attended  with  some  moist  crepitations  down  to  the 
second  rib.  Elsewhere  the  breath-sounds,  though  wanting  in  power, 
were  of  vesicular  quality.  The  pulse  was  quick  and  weak,  appetite 
indifferent,  but  digestion  fairly  good. 

The  patient  inherited  a  disposition  to  consumption,  having  lost  her 
mother  from  it  when  she  was  two  years  old ;  her  sister  had  also 
suffered  from  an  early  stage  of  the  disease. 

She  was  unable  to  leave  her  home,  and  could  only  be  induced  to 
partially  wean  the  child.  Under  tonic  treatment,  however,  with  cod- 
liver  oil  and  a  few  lozenges  to  relieve  the  cough  at  night,  she  decidedly 
improved,  gaining  in  health  and  strength,  and  putting  on  flesh  rapidly. 
A  month  later  the  moist  rales  were  no  longer  audible,  except  after 
cough,  which  elicited  a  few  crackles.  There  now  appeared  a  slight 
degree  of  flattening  below  the  left  clavicle,  more  distinct  on  deep 
inspiration.  The  respiratory  sounds  were  feeble,  while  on  the  opposite 
side  they  were  exaggerated,  and  careful  percussion  defined  the  margin 
of  the  healthy  lung  as  extending  slightly  beyond  the  median  line  at  the 
upper  sternum.  There  was  no  evidence  of  a  cavity  at  the  left  apex, 
nor  of  any  extension  of  the  area  of  disease.  The  pulse  was  quiet  but 
weak,  the  appetite  improved. 

Such  is  a  brief  account  of  an  average  case,  which  suggests 
the  following  considerations  : 

(i)  The  patient,  with  a  phthisical  family  history,  debilitated 
by  adverse  conditions — in  this  case  rapid  pregnancies  and 
depressed  circumstances  of  Hfe — presented  herself,  suffering 
from  a  wasting  illness  of  three  months'  duration,  attended 
with  definite  chest  symptoms.  We  can  but  rarely,  at  the  moment 
of  first  seeing  such  a  patient,  know  the  range  of  temperature 
or  whether  there  be  tubercle  bacilH  in  the  sputum;  but  the 
history  of  night-sweatings  and  wasting  would  assure  us  of  the 
one,  and  the  character  of  the  physical  signs  renders  an  exam- 
ination for  bacilH  in  such  a  case  of  less  importance,  for  these 
signs  reveal  a  definite  lesion  at  the  apex  of  the  lung,  which, 
under  such  circumstances,  is  almost  always  tuberculous. 


506  DISEASES   OF   THE   LUNGS   AND   PLEURA 

(2)  After  a  few  weeks'  treatment,  even  under  the  adverse 
circumstances  of  a  case  only  treated  as  a  hospital  out-patient, 
a  notable  improvement  was  observed  in  the  general  condition 
of  the  patient,  and  two  pulmonary  signs  presented  themselves 
of  clinical  importance  in  the  same  direction.  These  were 
(a)  the  fact  that,  with  diminished  crepitations,  showing  a 
lessened  activity  of  the  disease,  a  commencing  flattening  and 
an  impaired  mobility  of  the  chest  over  the  part  affected  was 
observed;  and  (b)  that,  on  careful  percussion,  to  define  the 
margin  of  the  healthy  (right)  lung,  it  is  found  to  extend 
towards  the  affected  side  up  to  and  a  little  beyond  the  median 
line.  These  two  signs — ^late  flattening,  coincident  with  lessened 
activity  of  disease  (as  contrasted  with  early  flattening-  from 
sheer  loss  of  lung  substance),  and  compensatory  expansion  of 
the  sound  lung  encroaching  upon  the  region  of  the  affected 
side — are  of  considerable  value  in  favour  of  the  hopeful 
prognosis  of  the  case. 

(3)  The  patient's  history  illustrates  an  important  point  in 
aetiology,  the  fact  that  a  lowered  resistance  favours  the  attack, 
and  reminds  us  of  another  important  point  in  prognosis, 
namely,  that  the  more  unfavourable  the  circumstances  which 
have  led  up  to  the  illness,  the  better  prospect  is  there  of  re- 
covery if  they  can  be  removed  or  mitigated.  "  It  is  true  that 
privation,  excess,  errors  in  habits  of  life,  the  sedentary  occu- 
pations, the  pernicious  influence  of  certain  trades,  grief, 
anxiety,  and  the  other  wasters  of  vital  powers,  will  not  suffice 
to  induce  consumption  in  all,  or  even  in  the  greater  propor- 
tion of  individuals ;  for  these  agents,  so  universally  prevalent, 
are  part  of  the  daily  lot  or  of  the  daily  errors  of  many  more 
than  fall  victims  to  consumption.  But  it  is  also  true  that,  if 
to  any  or  all  of  these  conditions  that  of  inherited  tendency  to 
phthisis  be  superadded,  very  few  indeed  escape  the  disease.'"' 
This  remark  is  well  borne  out  by  the  above,  amid  numberless 
other  cases  which  must  be  familiar  to  physicians,  although  we 
now  know  that  the  acquired  or  inherited  impairment  of 
resistance  operates  by  increasing  the  receptivity  to  a  definite 
infection  which  may  have  the  average  wide  distribution  to 
which  all  are  exposed,  or,  again,  which  may  be  more  concen- 
trated by  general  insanitation  or  specifically  infected  sur- 
roundings. 

Most  cases  of  "  cured  "  early-stage  phthisis  are  of  the  kind 


PLATE  XXIX 


.sXs^ 


Arrested  Tlberculosis. 


To  face  p.  507. 


ARRESTED  TUBERCULOSIS 

'  The  drawing  shows  the  posterior  half  of  the  left  lung.  The 
upper  lobe  is  seen  to  be  considerably  shrunken  and  converted 
into  a  dense  fibroid,  partly  pigmented  mass,  containing  one  or 
two  very  small  cavities,  in  one  of  which  a  little  calcareous  matter 
was  found.  No  recent  tuberculous  disease  is  seen.  The  right 
lung  also  showed  arrested  disease — in  the  upper  lobe  a  contracted 
cavity  the  size  of  a  filbert,  surrounded  by  fibroid  material ;  and 
in  the  lower  lobe  some  scattered  pigmented  tubercles  of  old  stand- 
ing, together  with  a  small  calcareous  patch  at  the  apex. 

From  a  man  aged  fifty-one,  who  died  from  acute  bronchitis, 
complicated  with  aortic  regurgitation  and  extensive  atheroma  of 
the  aorta.  The  tuberculosis  in  the  lungs  had  undergone  com- 
plete arrest. 

(From  the  Museum  of  the  Brompton  Hospital,     f  natural  size.) 


PLATE  XXIX 


CHRONIC   TUBERCULOSIS   OF   THE  LUNGS  507 

above  related.  The  arrest  of  the  disease  may  be  of  long-  or 
even  permanent  duration,  but  the  lesions  which  remain  in  the 
lung,  although  quiescent,  still  contain  entombed  within  them 
organisms  capable  of  fresh  germination  should  the  conditions 
again  prove  favourable.  Hence  the  previous  health-history 
of  the  patient  helps  us  much  in  the  prognosis  in  each  in- 
dividual case.  Those  cases  in  which  the  pulmonary  delicacy 
is  distinctly  inherited  are  the  least  hopeful;  those,  again,  in 
which  the  attack  has  been  most  distinctly  provoked  by 
adverse  conditions  of  a  definite  and  remediable  kind  are 
the  most  favourable.  Of  course,  in  each  case  the  extent 
of  lung  involved  and  the  intensity  of  the  disease,  to  be 
ascertained  only  by  physical  examination,  must,  as  already 
pointed  out,  most  materially  enter  into  the  question  as  to 
outlook. 

The  patient  whose  history  we  have  been  considering 
suffered  a  second  attack  after  the  lapse  of  some  months,  with 
extension  of  disease,  involvement  of  the  other  lung,  and  ulti- 
mately a  fatal  termination.  Such  is  the  average  tendency  in 
cases  of  this  type,  a  disposition  to  arrest  and  to  recurrence. 
It  must  be  here  remarked,  however,  that  with  arrest  of  disease 
a  certain  degree  of  immunity  is  gradually  established,  and 
provided  the  resistance  be  not  broken  down  by  premature 
return  to  the  vicissitudes  of  current  life  this  immunity  may 
result  in  complete  ability  to  withstand  the  test  of  acute 
influenzal  and  other  illness. 

Transition  from  Ordinary  Chronic  to  Fibroid  Phthisis.— All 
cases  of  chronic  pulmonary  tuberculosis  present  some 
evidence  of  repair,  some  attempt  at  arrest  of  the  disease  by 
the  formation  of  protecting  zones  of  fibrous  tissue  (Plate 
XXIX.).  In  patients  in  whom  the  natural  resistance  is  great, 
this  fibrosis  may  become  a  marked  feature,  and  in  extreme 
cases  may  warrant  the  appellation  "  fibroid  phthisis,"  a  condi- 
tion which  we  shall  presently  consider.  It  must  be  remem- 
bered, however,  that  such  fibrosis  constitutes  but  a  very 
imperfect  form  of  repair.  It  is,  in  fact,  the  replacement  of 
a  hig-her  by  a  lower  form  of  tissue,  which  may  be  regarded  as 
cicatricial,  and  which  often  proceeds  to  bring  about  deformi- 
ties and  other  morbid  conditions  of  its  own. 

The  following  case  exemplifies  fairly  well  the  transition 
stages  between  simple  chronic  pulmonary  tuberculosis  and 


■508  DISEASES   OF  THE  LUNGS   AND   PLEURA 

fibroid  phthisis,  a  transition  pathologically  easy,  and  clinically 
often  to  be  observed  : 

John   B ,   aged  twenty-nine,   a  butcher's  assistant,   came  under 

the  notice  of  one  of  us  as  an  out-patient  at  the  Brompton  Hospital. 
He  was  a  broad-chested,  powerfully-made  man,  of  medium  height  and 
florid  complexion.  He  had  led  a  rough  but  sober  life,  having  followed 
his  present  business,  which  included  the  slaughtering  of  animals,  for 
some  years  in  Australia,  and  had  enjoyed  excellent  health  until  shortly 
before  Christmas,  when,  after  getting  wet,  he  caught  a  severe  cold, 
which  was  followed  by  a  cough,  which  had  since  increased,  unin- 
fluenced by  treatment.  Up  to  and  at  the  time  of  his  attendance  in  the 
following  March  he  was  still  continuing  his  employment,  but  he  now 
did  so  with  difiiculty,  complaining  of  his  cough  and  of  increasing 
weakness,  with  decided  emaciation.  His  father  had  died  of  consump- 
tion, brought  on  subsequent  to  the  patient's  birth  by  intemperance; 
there  was  no  other  hereditary  tendency  to  the  disease. 

His  chest,  as  before  said,  was  broad  and  well-formed,  without 
flattening  or  obvious  impairment  of  expansion.  The  heart's  apex-beat 
was  in  the  natural  situation.  At  the  left  clavicular  and  subclavicular 
regions  the  percussion  note  was  dull,  the  dulness  extending  to  the 
fourth  rib ;  posteriorly  the  resonance  was  defective  at  the  left  supra- 
spinous fossa.  Scattered  over  the  dull  regions  there  was  coarse 
crepitation,  mingled  with  a  larger  humid  crackle.  These  moist  sounds 
were  abundant,  and  masked  to  a  great  extent  the  respiratory  murmur, 
which  was  decidedly  harsh,  but  not  distinctly  bronchial.  Its  vesicular 
quality  became  gradually  restored  as  the  stethoscope  was  passed 
downwards.  At  the  posterior  base  there  were  some  scattered  sibilant 
rales.  On  the  right  side  the  percussion  note  was  good,  and  the  breath- 
sounds  were  natural. 

The  physical  signs  at  the  present  stage  showed  consolidated  lobules 
of  blocked  alveoli,  which  were  softening  with  varying  degrees  of 
rapidity,  the  coarse  crepitation  answering  to  the  redux  crepitation  of 
pneumonia,  the  larger  click  being  due  to  more  profound  destruction  of 
tissue  (softening).  On  the  occasion  of  his  first  visit  the  pulse  was 
quick  and  the  tongue  red,  and  although  there  was  no  elevation  of 
temperature  at  the  moment,  it  is  probable  that  it  rose  slightly  towards 
evening. 

The  patient  was  treated  with  an  alkaline  mixture  containing  small 
doses  of  iodide  of  potassium,  and  with  cod-liver  oil.  A  few  weeks 
later  the  expansion  of  the  left  side  of  the  chest  was  found  to  be 
decidedly  impaired,  the  dulness  had  increased  in  hardness,  but  not  in 
extent,  and  was  very  marked,  especially  between  the  left  margin  of 
the  sternum  and  the  mid-clavicular  line. 

In  the  space  marked  out  by  these  two  vertical  lines  (left  sternal  and 
mid-clavicular)  the  respiration  was  extremely  feeble,  and  not  attended 
with  rales ;  the  heart's  impulse  was  diffused  upwards  to  the  second 
interspace,  though  the  apex  was  only  half  an  inch  higher  than  natural. 


CHRONIC  TUBERCULOSIS   OF  THE  LUNGS  509 

To  the  left,  again,  of  the  mid-clavicular  line  the  respiration  was  still 
feeble,  and  the  rales  much  diminished,  the  dulness  being  somewhat 
greater  than  before.  At  the  apex  posteriorly  there  was  bronchial 
respiration  with  imperfect  pectoriloquy ;  the  bronchial  rales  at  the  base 
had  cleared  up.  The  resonance  of  the  right  lung  extended  to  the  left 
margin  of  the  sternum. 

The  physical  signs  showed — 

1.  That  the  disease  had  not  extended;  on  the  contrary,  the 
signs  of  bronchial  irritation  at  the  base  had  cleared  up. 

2.  That  a  wasting"  of  the,  parenchyma  of  the  lung  had  taken 
place;  a  small  cavity  had  formed  at  the  apex,  with  collapse 
and  agglutination  of  air-cells  elsewhere,  thus  causing  a  con- 
siderable reduction  in  the  bulk  of  the  lung  and  retraction  of  its 
anterior  margin  from  the  median  line;  so  that  between  the  left 
sternal  line  and  a  line  drawn  from  the  point  of  junction  of 
the  inner  and  middle  third  of  the  clavicle  to  the  apex  of  the 
heart  there  was  probably  at  this  date  no  lung  at  all. 

3.  That  an  encroachment  of  the  enlarging  right  lung,  a  slight 
shifting  of  the  heart  to  the  left,  and  a  flattening  of  the  chest 
wall  had  ensued  to  make  up  for  the  lost  space.  The  flatten- 
ing was,  however,  as  yet  very  slight,  and  not  noticeable  until 
the  patient  drew  a  breath.  The  man  had  powerful  parietes, 
and  in  such  cases  the  displacement  of  heart  and  encroachment 
of  the  opposite  lung  precede,  often  for  a  long  time,  any 
obvious  flattening. 

It  was  remarkable  with  what  rapidity  these  changes  were 
taking  place,  and  there  can  be  no  doubt  that,  after  consider- 
able lung  destruction,  the  connective  tissue  of  the  bronchial, 
perivascular,  and  pleural  sheaths  was  undergoing  rapid 
development,  and  that  the  case  was,  in  fact,  lapsing  into  an 
early  stage  of  fibroid  phthisis.  That  the  disease  was  not  yet 
arrested  seemed  probable  from  the  patient  still  losing  slightly 
in  weight  and  becoming  more  anaemic;  but  it  had  clearly 
become  Hmited. 

During  the  next  month  (May),  although  taking  an  acid  preparation 
of  iron,  with  a  little  quinine,  and  the  oil,  he  lost  two  pounds  in  weight. 
Notwithstanding  this,  he  had  improved  generally ;  the  cough  and 
expectoration  had  diminished,  and  he  felt  stronger.  On  June  8  he 
was  still  better,  and  had  regained  one  pound  since  the  last  report.  He 
had  very  little  cough ;  all  moist  sounds  had  disappeared  except  a  slight 
pleuritic  rale  on  cough  at  the  outer  side  and  a  little  above  the  left 
nipple.  He  steadily  improved  up  to  August,  five  months  after  his  first 
attendance  at  the  hospital,  when  he  was  lost  sight  of. 


510  DISEASES   OF  THE  LUNGS   AND   PLEURA 

REFERENCES. 

^  "  The  Significance  of  Arneth's  Reaction,  with  Particular  Reference  to 
Pulmonary  Tuberculosis."  By  H.  A.  Treadgold,  M.D.,  The  Lancet,  1920, 
vol.  i.,  p.  699. 

'  "  The  Role  of  the  Cardio-vascular  System  in  Pulmonary  Tuberculosis." 
By  Sir  R.  Douglas  PoweU,  Bart,  K.C.V.O.,  M.D.,  F.R.C.P.,  TU  Lancet, 
1912    vol.  ii.,  p.   1415. 

^  Eleme?its  of  Prognosis  in  Consumption,  with  Indications  for  the  Pre- 
vention! and  Treatment.  By  James  Edward  Pollock,  M.D.,  p.  340. 
London,  1865. 


CHAPTER   XXXV. 

CHRONIC  TUBERCULOSIS  OF   THE  l.\J^GS— Continued 

Fibroid  Phthisis. 

fuE  term  "  fibroid  phtliisis  "  has  been  productive  of  much  dis- 
cussion. It  was  orig-inally  introduced  by  the  late  Sir  Andrew 
Clark^  to  "  embrace  all  those  cases,  whether  local  or  consti- 
tutional, which  are  anatomically  characterised  by  the  presence, 
in  a  contracted  and  indurated  lung  traversed  by  more  or  less 
dilated  bronchi,  of  fibroid  tissue  and  of  a  tough  fibrogenous 
substance,  together  with  cheesy  deposits  or  consolidations, 
and  usually  small  cavities,  commonly  found  about  the  middle 
and  lower  parts  of  the  affected  organ."  The  term  is  such  a 
neat,  concise  and  clinically  useful  one,  that  it  has  been  gener- 
ally accepted,  with  some  reservations  as  regards  the  strict 
pathology  of  the  disease  as  originally  enunciated  by  its  author. 
Indeed,  at  the  present  day  its  use  is  restricted  to  cases  of 
pulmonary  tuberculosis  of  an  extremely  chronic  type,  in  which 
the  resistance  of  the  patient  is  considerable,  and  the  forma- 
tion of  much  fibrous  tissue,  with  its  attendant  consequences, 
has  resulted. 

The  prominent  symptoms  and  signs  by  which  cases  of 
fibroid  phthisis  are  distinguished  are  :  increasing  contraction 
and  immobility  of  the  affected  side;  traction  of  organs  to  that 
side;  deadened  percussion  note  and  weakened  breath-sounds 
of  more  or  less  bronchial  quahty,  at  parts  intensely  bronchial 
or  cavernous;  breathlessness;  dragging  pains;  paroxysmal 
cough;  occasional  hectic,  but  general  absence  of  fever;  very 
chronic  progress;  long-continued  one-sidedness  of  the  disease, 
and  correspondingly  slow  failure  of  nutrition.  Such  symptoms 
and  signs  bring  the  cases  within  the  definition  of  phthisis,  but 
phthisis  of  a  special  type. 

511 


512  DISEASES   OF  THE  LUNGS   AND  PLEURA 

The  conditions  presented  post-mortem  are  those  of  a  con- 
tracted, toughened,  indurated,  and  usually  pigmented  lung, 
surrounded  by  a  greatly  thickened  adherent  pleura  contain- 
ing one  or  more  rigid,  dense-walled  cavities,  dilated  bronchi, 
and  cheesy  encapsuled  nodules. 

On  minute  examination  this  condition  of  lung  is  found  to 
have  been  produced  by  a  growth  of  two  kinds  pervading  its 
texture :  (i)  a  connective-tissue  proliferation,  resulting-  in  the 
formation  of  bands  and  processes  of  fibrous  tissue,  derived 
from  the  sheaths  of  vessels  and  bronchi  and  the  subpleural 
and  interlobular  tissue  of  the  lung;  (2)  a  more  important 
nuclear  growth  originating  in  a  fibroid  transformation  of  the 
individual  tubercles,  and  resulting  in  the  formation  of  broad 
tracts  of  fibroid  tissue,  which  thicken  the  walls  of  the  alveoli, 
compress,  and  finally  efface  them,  unless  they  have  been 
previously  stuffed  with  their  own  inflammatory  products. 
(3)  In  some  small  foci  the  process  proceeds  to  slow  caseation 
and  softening.  In  other  cases,  as  in  that  described  in  the 
previous  chapter,  a  considerable  destruction  of  the  lung  may 
have  preceded  the  fibrosis. 

The  products  of  these  processes  become  intimately  mingled, 
but  it  is  the  tuberculous  element  which  gives  to  the  disease  its 
peculiar  clinical  features,  and  renders  the  name  "  fibroid 
phthisis  "  appHcable  to  it. 

Numerous  examples  may  be  found  of  this  somewhat  inclu- 
sive disease,  ranging  from  the  most  typical  cases  to  those 
which  are  almost  indistinguishable  from  ordinary  chronic 
phthisis.  We  have  described  in  the  preceding  chapter  a  case 
of  simple  chronic  pulm.onary  tuberculosis,  in  which  the^  transi- 
tion into  one  of  early  fibroid  phthisis  was  traced.  It  would 
not  be  difficult,  however,  to  find  examples  in  which  the  reverse 
takes  place,  the  clinical  characters  of  fibroid  phthisis  being 
gradually  changed  by  subsequent  activity  of  the  tuberculous 
process,  and  all  the  features  of  the  special  variety  becoming 
merged  in  the  diffuse  pulmonary  destruction.  Thus  in  a  boy, 
to  whose  case  allusion  was  made  in  a  former  edition  of  this 
work,  the  disease  beg^an  with  tuberculous  destruction  of  a 
certain  portion  of  lung,  upon  arrest  of  which  the  marked 
phenomena  of  pulmonary  fibrosis  supervened,  and  finally, 
again,  active  destructive  changes  set  in,  quite  obscuring  the 
fibroid  characters,  and  resulting  in  death  from  pneumothorax. 


CHRONIC  TUBERCULOSIS  OF  THE  LUNGS 


513 


The  following  case  is  a  fair  example  of  the  variety  of  tuber- 
culosis now  under  consideration : 

George  P.,  a  sawyer,  aged  forty-three  when  he  first  came  under 
observation  as  an  out-patient  at  the  Brompton  Hospital,  was  a  thin 
man,  with  dark  hair,  having  no  hereditary  predisposition  to  lung 
disease,  except  that  his  father  had  suffered  from  "  asthma."  He  had 
had  slight  cough  for  years,  and  in  the  preceding  winter  had  been  laid 
up  for  six  weeks  with  "  inflammation  of  the  right  lung."  Since  that 
time  the  cough  had  been  continuous,  and  there  had  once  been  slight 
haemoptysis.  The  cough  was  now  paroxysmal,  causing  retching  and 
often  rejection  of  food ;  expectoration  difficult,  abundant,  and  of  a  pink 
tinge.  He  had  lately  been  losing  weight.  The  digestive  functions  were 
fairly  good ;  the  pulse  a  little  hurried ;  there  was  no  fever. 


Fig.  52. 

On  inspecting  the  chest,  cardiac  pulsation  was  visible  at  the  fourth 
right  interspace  (Fig.  52,  C)  to  left  of  right  nipple.  This  side  was 
diminished  in  size  and  much  restricted  in  movement,  the  intercostal 
spaces  deepening  with  inspiration,  while  the  left  side  expanded  freely, 
with  an  uplifting  movement  of  the  shoulder.  On  careful  examination, 
the  apex  of  the  heart  was  found  a  little  to  the  left  of  the  ensiform 
cartilage. 

On  percussion,  the  right  side  in  the  nipple-line  anteriorly  was  dull  to 
the  second  rib  (A),  comparatively  resonant  to  the  fourth,  and  below 
this  point  it  v^as  again  toneless.  The  resonance  of  the  left  lung 
extended  to  the  right  of  the  sternum,  as  indicated  in  the  diagram.  The 
line  of  this  resonance  (D)  sloped  upwards  to  the  episternal  notch,  being 
displaced  in  a  downward  direction  by  cardiac  dulness  at  the  fourth 

33 


514  DISEASES   OF   THE   LUNGS   AND   PLEUTLE 

cartilage.  Hepatic  dulness  barely  reached  the  costal  margin.  There 
was  dulness  throughout  the  axillary  region  and  posteriorly  from  apex 
to  mid-scapula,  the  note  having  a  tubular  quality  in  this  latter  region. 
Below  the  mid-scapula  there  was  fair  resonance  to  the  ninth  rib, 
though  less  and  harder  than  on  the  opposite  side;  the  lower  two  or 
three  inches  on  the  right  side  gave  a  flat  note  on  percussion. 

The  percussion  note  over  the  whole  left  side,  including  the  region  of 
normal  cardiac  dulness  and  extending  across  the  median  line,  as  above 
indicated,  was  full  and  good  in  front  and  behind. 

The  auscultatory  signs  were  in  agreement  with  those  of  percussion. 
Above  the  clavicle  on  the  right  side  the  respiration  was  amphoric  and 
dr}' ;  below  the  clavicle  weak  and  bronchial  to  the  base,  with  some 
rather  large  moist  rales,  friction  and  bronchophony^  At  one  spot, 
corresponding  with  the  second  and  third  ribs  in  the  nipple-line  (B)  the 
breath-sound  was  of  tracheal  quality,  with  scanty  cavernous  clicks  and 
pectoriloquy.  In  the  upper  axillary  region  the  respiration  was 
amphoric,  and  the  voice-sound  pectoriloquous ;  in  the  supraspinous 
fossa  and  interscapular  regions,  cavernous-blowing  with  pectoriloquy. 
Blowing  respiration  extended  to  the  angle  of  the  scapula,  where  it 
became  weaker  and  gradually  annulled  at  the  base.  The  vocal  fremitus 
was  generally  increased  on  the  right  side.  Respiration  throughout  the 
left  lung  was  exaggerated  and  vesicular. 

At  the  end  of  six  months  the  patient  had  improved  in  flesh,  appear- 
ance, and  in  strength,  but  complained  greatly  of  cough,  and  expec- 
torated much  pink  phlegm.  Breath  short  on  exertion ;  cough  caused 
retching,  but  no  rejection  of  food;  appetite  fair;  digestion  not  very 
strong ;  bowels  regular.     Fingers  observed  to  be  clubbed. 

The  additional  physical  sign  noted  at  this  date  was  a  distinct  short 
systolic  bruit  at  the  point  of  maximum  cardiac  impulse,  not  appreciably 
increased  by  pressure  nor  confined  to  that  spot,  being  also  audible  at 
the  apex.  Measurements  of  chest  :  from  mid-sternum  to  nipple,  right 
side,  4  inches;  semi-circumference,  15I  inches;  expansion,  |  inch. 
Left  sterno-nipple  measurement,  4I  inches;  semi-circumference, 
16  inches;  expansion,  5  inch. 

We  may,  by  way  of  summary,  aided  by  a  glance  at  the 
figure  (reduced  as  accurately  as  possible  from  a  sketch  taken 
at  the  time  upon  an  outline  diagram),  interpret  the  above 
detailed  physical  signs  as  indicating  at  this  period  a  general 
induration  of  the  right  lung,  with  much  contraction,  its 
anterior  margin  having  receded  considerably  from  the  median 
line,  exposing  the  pericardium,  and  having  also  shrunk  away 
from  the  upper  surface  of  the  liver.  Its  upper  lobe,  and  a 
portion  of  its  lower,  were  extensively  excavated,  the  cavities 
being  old,  tolerably  dry,  and  shrunken  with  the  general  con- 
traction of  the  lung.  The  pleura,  judging  from  the  hardness 
of  percussion,  feebleness  of  breath-sound,  and  fixity  of  chest 


CHRONIC   TUBERCULOSIS   OF  THE  LUNGS  515 

walls,  was  probably  greatly  thickened.  The  liver  was  drawn 
up  within  the  costal  margin,  and  the  heart  considerably  dis- 
placed to  the  right,  its  axis  being,  however,  but  little  altered. 

His  chest  was  repeatedly  examined  during  the  many  subsequent 
months  of  his  attendance  at  the  hospital,  but  beyond  some  variation  in 
the  dryness  of  the  sounds,  there  was  no  important  change  in  the 
physical  signs.  The  urine  was  more  than  once  examined,  but  was 
always  found  free  from  albumin. 

The  left  lung  remained  healthy,  and  though  the  patient  continued 
thin  and  cachectic-looking,  with  a  troublesome  cough,  he  held  his 
ground  fairly  well,  and  rather  improved  in  general  health.  At  times 
the  expectoration  would  become  very  abundant,  and  occasionally  of  a 
pink  colour,  probably  due  to  fresh  irritation  and  slight  sanguineous 
discharge  from  the  walls  of  the  old  cavities.  The  most  troublesome 
symptom  throughout  the  case,  and  one  which  is  common  in  greater  or 
less  degree  to  all  those  cases  of  tuberculosis  in  which  indurated  thick- 
walled  cavities  are  present,  was  the  paroxysmal  cough  terminating  in 
vomiting,  occurring  especially  after  meals. 

On  ceasing  attendance  at  the  hospital,  after  a  period  of  nine  months, 
the  patient,  though  not  free  from  cough,  continued  for  a  time  to 
improve,  but  he  soon  afterwards  began  again  to  emaciate,  and  the 
vomiting  with  cough  returned.  He  again  attended  in  January  the 
following  year  for  three  months,  and  improved. 

The  above-related  case  represents  very  well  the  main 
features  of  fibroid  disease  of  the  lung.  The  indurative  disease 
supervened  presumably  upon  an  acute  tuberculous  pneumonia 
affecting  the  upper  part  of  the  right  lung,  and  manifested  it- 
self with  tolerable  rapidity,  the  characteristic  symptoms  and 
signs  being  fully  developed  within  six  months  of  the  termina- 
tion of  the  acute  disease. 

The  question  as  to  the  rapidity  with  which  this  disease  may 
advance  is  one  of  great  interest,  and  requiring  further  observa- 
tion. We  cannot  but  think  that,  reasoning  from  the  morbid 
appearances  found  in  the  post-mortem  room,  we  are  apt  to 
regard  such  diseases  as  older  than  the  clinical  history  will 
warrant  us  in  beHeving;  on  the  other  hand,  though  it  is 
probable  that  the  fibroid  induration  of  the  lung  may  proceed 
with  great  rapidity  to  such  a  stag"e  of  shrinking  as  to  produce 
marked  clinical  signs,  its  subsequent  progress  is  very  slow  and 
difficult  to  measure,  consisting  mainly  in  the  further  harden- 
ing of  an  already  indurated  lung,  the  gradual  widening  of  the 
bronchial  tubes,  and  filling  up  of  the  loose  oedematous  areolar 
tissue  between  the  separated  pleural  layers  by  dense  fibrous 


5l6  DISEASES   OF  THE  LUNGS   AND   PLEURA 

growth.  We  can  readily  perceive,  therefore,  how  its  earHer 
stages,  which  are  attended  with  striking  alterations  in  physical 
signs,  may  be  passed  through  with  comparative  rapidity,  while 
the  later  progress  is  necessarily  slow  and  difficult  to  estimate. 
No  doubt  the  mechanical  conditions  of  the  cavities  to  which 
we  have  referred,  and  which  render  the  removal  of  expectora- 
tion difficult,  have  much  to  do  with  the  production  of  vomit- 
ing, and  cause  it  to  be  a  particularly  common  symptom  in  these 
cases;  but  the  reception  of  food  into  the  stomach  has  seemed 
to  be  in  many  cases  so  constantly  followed  by  cough  ending 
in  vomiting  as  to  render  this  mechanical  explanation  in- 
sufficient, and  we  have  been  led  to  attribute  it  to  an  undue  reflex 
irritability  of  the  pneumogastric  nerve. 

The  following  notes  of  a  patient  who  had  been  under  obser- 
vation at  the  Brompton  Hospital  for  more  than  forty  years 
illustrate  the  great  chronicity  which  this  form  of  the  disease 
may  sometimes  attain : 

E.  P.  was  admitted,  at  the  age  of  seventeen,  into  the  hospital,  under 
the  care  of  our  colleague,  the  late  Dr.  Pollock,  in  November,  1877,  for 
cough  and  weakness  of  seven  years'  duration,  having  also  had  slight 
haemoptysis  in  1874.  On  her  mother's  side  there  was  a  predisposition 
to  phthisis,  her  maternal  grandmother  and  uncle  having  both  died  of 
this  complaint ;  and  twelve  years  later,  in  1889,  her  mother  herself 
succumbed  to  it. 

The  physical  signs  on  admission  were,  to  quote  Dr.  Pollock's  note, 
"on  the  right  side  dulness,  flattening,  and  cavernous  breathing,  with 
gurgling  and  humid  crepitations  to  the  anterior  base  and  in  the  axilla. 
In  the  supraspinous  fossa  some  cavernous  sounds  were  heard.  The 
respiration  was  tubular  in  the  interscapular  region.  Some  crackles 
were  heard  at  the  posterior  base.  The  left  lung  reached  to  the  right 
border  of  the  sternum;  no  abnormal  sounds  were  heard  over  it."  On 
January  17,  1878,  the  right  lung  was  found  to  be  dry,  except  for  a  few 
fine  crackling  sounds  after  cough  in  the  infraclavicular  region.  The 
posterior  base  was  clear. 

In  February,  1878,  the  patient  left  the  hospital  greatly  improved,  her 
weight  now  being  7  stone  3I  pounds,  a  gain  of  6|  pounds  since 
admission.  After  leaving,  she  remained  fairly  well  for  some  years, 
though  suffering  on  and  off  from  cough. 

In  1892  she  again  entered  the  hospital,  under  Dr.  Mitchell  Bruce, 
and  again  derived  benefit. 

On  October  9,  1899,  she  came  under  Dr.  Hartley's  observation  at  the 
hospital,  complaining  that  her  cough  had  been  worse  lately  and  her 
breath  shorter.  Her  general  condition  was  fair,  though  her  appetite 
was  poor.     Her  height  was  about  5  feet  3  inches,  her  weight  6  stone 


CHRONIC  TUBERCULOSIS   OF  THE  LUNGS 


517 


II  pounds.  On  examination,  tlie  right  side  was  flattened  with  but 
very  poor  expansion,  and  yielded  all  over  a  markedly  impaired  note  to 
percussion.  The  heart  was  drawn  to  the  right  side  of  the  sternum, 
and  pulsation  extended  as  far  as  the  right  anterior  axillary  line 
(Fig.  53,  A).  Cavernous  breath-sounds  were  heard  over  extended 
areas  of  the  right  lung,  with  scattered  crepitations.  The  left  lung 
seemed  free  from  disease  and  to  be  hypertrophied,  extending  for 
about  an  inch  to  the  right  of  the  sternum  (B).  There  was  no  clubbing 
of  the  fingers. 

The  diagrams  (Figs.   53  and  54)  show  the  condition  of  the  chest, 
which  was  but  little  different  from  that  observed  by  Dr.  Bruce  in  1892. 


Fig. 


53- 


In  June,  1900,  she  had  improved  in  every  way,  although  her  cough 
continued.  In  January,  1901,  her  weight  was  still  6  stone  11  pounds, 
and  her  physical  signs  showed  no  change,  except  that  now  some 
crepitations  were  heard  at  the  apex  of  the  left  lung  posteriorly.  In 
the  expectoration,  which  was  never  very  large  in  amount,  a  few 
tubercle  bacilli  were  found. 

From  1901  to  1906  the  patient  was  under  our  observation  from  time 
to  time,  and,  on  the  whole,  somewhat  improved.  In  May,  1903, 
her  weight  was  7  stone  6^  pounds,  and  in  May,  1906,  7  stone  8  pounds. 
On  the  latter  date  crepitations  were  still  audible  at  the  left  apex,  but 


5i8 


DISEASES  OF  THE  LUNGS  AND  PLEURA 


showed  no  signs  of  extending.  She  was  still  able  to  carry  on  her 
occupation  as  a  needlewoman. 

Since  igo6Bhe  has  lived  in  London,  and  has  kept  fairly  well,  though 
subject  to  bronchial  attacks  in  the  winter,  when  her  cough  and 
breathing  become  troublesome.  Apart  from  these  attacks  she  has 
had  very  little  cough  or  phlegm.  In  1910  she  suffered  from  an 
abscess  in  the  right  breast,  which  her  doctor  regarded  as  tuberculous. 
It  discharged  for  about  twelve  months  and  then  healed. 

On  February  25,  1920,  she  came  at  our  request  to  the  hospital  for 
examination.  Her  age  was  now  fifty-nine.  She  looked  well  in  herself, 
but  was  somewhat  short  of  breath  on  exertion.    Weight,  7  st.  25  lbs. 


>      Fig.  54. 

There  was  but  little  change  in  the  pulmonary  condition.  The  right 
lung  was  contracted  and  excavated,  and  the  right  side  ex- 
panded but  little  on  inspiration.  The  note  at  the  left  apex 
was  still  slightly  impaired,  and  a  few  moist  sounds  were  audible 
in  this  region,  but  there  appeared  to  have  been  no  extension  of 
the  tuberculous  disease  since  her  last  appearance  in  1906.  The  heart 
was  drawn  over  to  the  right  side  as  before,  but  the  blood-pressure  was 
now  distinctly  raised,  measuring  in  the  right  brachial,  in  the  sitting 
posture,  170  mm.  Hg.  The  second  aortic  sound  was  rather  forcible. 
The  urine  was  of  low  specific  gravity,  and  contained  no  albumin  or 
sugar.     The  spleen  and  liver  were  not  enlarged,   and  there  was  no 


CHRONIC  TUBERCULOSIS  OF  THE  LUNGS       51.9 

diarrhoea,  or  any  evidence  of  lardaceous  degeneration.  Her  sight 
was  beginning  to  fail,  and  she  was  now  unable  to  continue  her  needle- 
work. 

This  case  is  of  great  interest  in  that  the  signs  have  been 
traced,  through  a  period  of  forty-three  years,  from  an  apical 
disease  to  one  involving  the  whole  lung  and  coming  into 
the  category  of  fibroid  phthisis.  In  spite,  also,  of  the  long 
duration  of  the  case,  the  affection  of  the  opposite  lung 
remains  but  slight.  She  appears  indeed  to  have  long  attained 
arrest  of  the  tuberculous  disease,  and  for  some  thirty  years 
to  have  enjoyed  fair  health,  though  possessing  only  one 
functionating  lung. 

Prognosis. — The  outlook  in  fibroid  phthisis  varies  with  the 
somewhat  diverse  cases  grouped  together  under  this  headings. 
The  disease,  however,  may  be  said  to  be  very  chronic,  and 
capable  in  a  considerable  number  of  cases  of  permanent  arrest. 
There  are,  however,  certain  points  to  be  taken  into  account 
in  estimating  the  duration  of  a  case.  The  cachexia  may  be 
marked,  almost  resembling"  that  of  some  cases  of  cancer.  The 
wall  of  a  chronic  cavity  may  be  traversed  by  a  large  vessel, 
which,  yielding  on  its  unsupported  side,  forms  an  aneurism, 
and  gives  rise  to  recurrent  or  fatal  haemoptysis.  Out  of  eight 
well-marked  cases  in  which  post-mortem  examinations  were 
made  by  one  of  us,  haemoptysis  was  the  cause  of  death  in  two.^ 

The  opposite  lung  in  most  cases  becomes  in  course  of  time 
involved  at  the  apex  with  secondary  tubercle,  but  this  is 
usually  of  the  grey  miliary  type,  and  generally  chronic  or 
quiescent.  This  is  exemplified  by  the  case  of  E.  P.,  above 
related,  and  also  by  that  of  a  patient  who  was  brought  by  one 
of  us  before  the  CHnical  Society  so  far  back  as  1868.  In 
association  with  chronic  destructive  lesion  of  the  left  lung, 
this  patient  had  also  distinct  evidence  of  involvement  of  the 
apex  of  the  opposite  lung,  and,  in  addition,  a  small  quantity 
of  albumin  in  the  urine.  He  subsequently,  however,  led  a 
rural  life,  and  his  health  yearly  improved.  The  right  limg 
became  greatly  enlarged,  the  disease  in  the  left  remaining 
perfectly  obsolescent,  and  the  patient  was  in  1885  in  good  flesh 
and,  to  all  appearance,  in  robust  health. 

In  the  later  stages  lardaceous  changes  in  various  organs, 
especially  the  spleen,  liver,  and  kidneys,  commonly  supervene, 
and  may  lead  to  the  death  of  the  patient.     Of  the  three  most 


5^0  DISEASES  OF  THE  LUNGS  AND  PLEUR/E 

characteristic  cases  in  which  we  have  made  post-mortem 
examinations,  in  one  there  was  extensive  lardaceous  degenera- 
tion of  liver  and  spleen  with  granular  kidneys;  in  another 
of  the  spleen  only.  Albumin  in  the  urine,  absent  in  the 
above-related  case,  is  often  the  earliest  clinical  evidence  of 
this  change. 

The  condition  of  health  and  physique  maintained  by  some 
patients  is  remarkably  good.  We  have  notes  of  a  postman 
presenting  exceedingly  well-marked  signs  of  this  form  of 
tuberculosis,  who  almost  entirely  lost  his  cough  while  attend- 
ing the  hospital,  and  was  able  to  resume  his  duties,  walking 
fourteen  or  fifteen  miles  a  day;  and  we  might  mention  some 
other  patients  capable  of  considerable  physical  exertion  on 
level  ground.  Persons  who  for  many  years  have  had  one 
lung  dormant  or  "  gone,"  as  they  usually  describe  it,  are  not 
uncommonly  met  with,  and  belong  to  this  category.  Mention 
has  already  been  made  of  two  such  cases,  and  we  can  also 
recall,  amongst  others,  that  of  a  lady  who  for  thirty  years  had 
her  left  lung  similarly  affected.  This  patient  led  a  sheltered 
but  useful  life,  and  rarely  suffered  from  pulmonary  symptoms 
of  any  kind.  Her  chief  complaint  from  time  to  time  was  of 
failure  of  heart's  action,  causing  chilliness  and  a  disposition 
to  fainting,  with  occasional  attacks  of  great  cardiac  oppres- 
sion, which,  but  for  the  absence  of  any  severe  pain,  would  be 
described  as  angina.  There  was  no  evidence  in  this  case  of 
valvular  disease  or  decided  dilatation  of  heart,  but  the  organ 
was  uncovered  by  the  retracted  left  lung,  and  the  sounds  were 
feeble.  We  have  observed  in  many  chronic  left-sided  cases 
of  tuberculosis  great  functional  disturbance,  or  rather  irrit- 
ability of  heart,  doubtless  attributable  to  its  being  less 
supported  and  protected  by  lung  than  in  health. 

REFERENCES. 

*  "A  Case  of  Fibroid  Phthisis,"  by  Andrew  Clark,  M.D.,  Transactions 
of  the  Clinical  Society  of  London,  1868,  vol.  i.,  p.  188. 
^  For  an  account  of  these  cases,  see 

(i)  "  Three  Cases  of  Phthisis  with  Contracted  Lung,"  by  R.  Douglas 
Powell,  M.D.  (Case  I.),  Transactions  of  the  Clinical  Society  of 
London,  1869,  vol.  ii.,  p.  181. 
(2)  "  Some  Cases  illustrating  the  Pathology  of  Fatal  Haemoptysis  in 
Advanced  Phthisis,"  by  R.  Douglas  Powell,  M.D.  (Table,  p.  58, 
Case  I.,  F.  W.),  Transactions  of  the  Pathological  Society  of  London, 
1871,  vol.   xxii.,  p.  41. 


CHAPTER  XXXVI 

TUBERCULOUS    EXCAVATION    OF    THE   LUNG— THE   CAVITY 

STAGE   OF    PHTHISIS 

The  excavation  stage  of  some  cases  of  phthisis  is  so  pro- 
longed, and  the  symptoms  are  so  decidedly  grouped  about  the 
cavity,  that  at  some  schools  it  is  the  custom  to  name  them 
cases  of  "cavitation."  Whilst  we  do  not  regard  such  a  term 
as  admissible  in  any  formal  sense,  however  appropriate  it 
may  be  as  a  colloquial  expression  in  clinical  teaching,  there 
are  yet  many  points  in  the  diagnosis  and  treatment  of  different 
kinds  or  conditions  of  cavities  which  are  worthy  of  considera- 
tion in  a  separate  chapter. 

We  have  seen  that  destruction  of  lung  is  the  essential  ana- 
tomical feature  of  pulmonary  tuberculosis.  In  the  most 
rapidly  fatal  cases  the  destruction  takes  place  simultaneously 
at  many  centres,  or  involves  such  an  extent  of  lung  as  to 
render  hopeless  any  effort  at  repair  or  compensation.  But  in 
a  large  proportion  of  cases  the  disease  affects  principally  one 
apex,  the  active  symptoms  attendant  upon  the  pulmonary 
consolidation  and  softening  after  a  time  subside,  the  appetite 
returns,  and  the  patient  begins  to  regain  strength  and  flesh. 
The  cough  still  continues,  however,  and  auscultation  reveals 
the  existence  of  a  cavity  at  the  apex  concerned,  the  disease 
being  now  usually  described  as  having  advanced  from  the  first 
(consolidation)  through  the  second  (softening)  to  the  third 
(cavity)  stage. 

If  these  terms  were  strictly  employed  in  a  structural  or 
anatomical  sense  as  regards  the  lungs  only,  they  would  not  be 
objectionable ;  but,  in  fact,  they  are  too  often  extended  in  their 
application  to  the  whole  disease  as  it  affects  the  patient,  and 
therefore  become  fruitful  of  error  and  misunderstanding. 
These  so-called  stages  of  phthisis  have  reference  merely  to 

521 


522  DISEASES   OF  THE  LUNGS  AND   PLEURA 

the  local  effects  of  that  disease,  involving  perhaps  a  fiftieth 
part  or,  it  may  be,  a  large  portion  of  one  or  both  lungs;  they 
have  no  meaning  as  apphed  to  the  present  or  prospective 
duration  of  the  disease.  A  man  with  a  big  cavity  is  frequently 
better  off  as  regards  life  and  health  prospects  than  one  with 
a  "  first  stage  "  patch  of  disease  no  larger  than  the  area  of  a 
shilling.  A  cavity  once  formed  is  so  much  lung  gone,  and  it 
is  for  many  reasons  better  that  the  irremediably  diseased 
portion  should  be  cleared  out  than  that  it  should  remain  as 
a  centre  for  fresh  irritation,  which  may  break  down  or  infect 
the  system  at  any  time.  Our  anxiety  as  regards  the  immedi- 
ate prognosis  rests  upon  the  condition  of  the  outlying  portions 
of  the  affected  lung,  and  still  more  upon  the  degree  of  integrity 
of  the  opposite  lung.  Yet  the  student  rarely  looks  beyond 
a  cavity,  upon  the  discovery  of  which  he  is  apt  to  classify  the 
case  and  to  decree  the  fate  of  the  patient.  The  physician,  too, 
is  often  beset  by  anxious  inquiries  from  relatives  and  friends 
as  to  the  existence  or  non-existence  of  a  cavity,  upon  which 
they  base  their  hopes  and  fears,  and  upon  his  capacity  to  dis- 
cover which  his  reputation  is  registered  in  their  estimation. 
These  terms,  then,  being  inaccurate  and  misleading,  should 
never  be  used  in  their  general  sense. 

To  resume,   however,  the  special   subject   of  the   present 
chapter.     Cavities    may   be    considered    under    four    heads : 
(i)  the  recent  cavity;  (2)  the  quiescent  cavity;  (3)  the  secret- 
ing cavity;  (4)  the  active  or  ulcerous  cavity. 

I.  Recent  CaYity. — The  recent  cavity  is  the  first  result  of 
the  breaking  down  of  caseous  nodules  in  the  lung.  In  cases 
of  sufficient  intensity  these  undergo  softening  and  liquefac- 
tion in  few  or  many  centres.  We  do  not,  however,  obtain  any 
physical  sign  of  the  production  of  a  cavity  until  communica- 
tion is  effected  with  a  bronchus  and  some  of  the  softened 
matter  is  expelled.  From  this  moment  we  have  cavities 
existing-  in  the  lungs  and  accessible  to  the  air  during 
respiration. 

To  yield  the  auscultation  signs  which  are  regarded  as 
necessary  for  diagnosis,  a  cavity  must  have  the  dimensions 
of  a  walnut,  or  larger,  and  must  communicate  freely  with  a 
bronchus.  But  on  comparing  our  clinical  notes  with  post- 
mortem observations  we  shall  find  the  former  most  commonly 
inadequate  if  we   have   awaited   the   presence   of  cavernous 


TUBERCULOUS  EXCAVATION  OF  THE  LUNG  523 

breathing  and  pectoriloquy,  and   such-like   orthodox   signs, 
before  admitting  the  existence  of  excavation. 

The  pulmonary  consolidations  break  down  into  cavities  in 
one  of  two  ways,  which  are  not,  however,  essentially  different. 
In  the  first  case,  many  minute  lobular  centres  of  softening  are 
found  which  yield  to  auscultation  moist  crackling  or  humid 
clicking  sounds;  these  increase  in  size -and  abundance  as  the 
softening  centres  extend  and  coalesce  into  larger  cavities, 
until  finally  we  have  cavernous  rales.  The  respiratory  murmur 
which — bronchial  with  the  first  consolidation — had  become 
weakened  and  more  or  less  masked  by  the  moist  sounds,  be- 
comes again  audible,  but  much  altered  in  quality,  assuming  the 
more  or  less  distinctly  cavernous  character.  Whispering 
pectoriloquy  now  becomes  marked,  and  in  some  cases  a 
characteristic  succussion  of  air  may  be  heard  on  coughing,  the 
so-called  "  post-tussive  suction."  On  percussion,  the  note  over 
a  cavity  is  usually  impaired  owing  to  consolidation  of  the 
surrounding  lung,  but  over  extensive  excavation  with  thin 
walls,  tubular  or  amphoric  resonance  may  be  obtained  (p.  39), 
with  possibly  the  bruit-de-pot  file,  if  the  cavity  be  near  the 
surface,  and  if  it  eommunicates  freely  with  a  bronchus. 

Perhaps  the  large  majority  of  phthisical  cavities  form  and 
increase  in  the  way  thus  briefly  sketched,  but  in  some  cases 
they  are  produced  in  a  slightly  different  manner.  It  may 
happen  that  we  fail  to  obtain  distinct  evidence  of  pulmonary 
softening  for  a  time,  when  troublesome  dry  cough  and  hectic 
symptoms  point  strongly  to  its  presence.  There  may  be  dul- 
ness,  harsh  breathing,  and  some  fine  spongy  crepitation, 
increased  after  cough,  but  none  of  those  distinct  clicks 
characteristic  of  pulmonary  softening.  Then  the  patient  will 
suddenly,  in  the  course  of  the  night,  perhaps,  expectorate  a 
considerable  quantity  of  purulent  matter,  and  we  find  evidence 
— cavernous  rales,  etc. — of  the  existence  of  a  cavity.  The  ex- 
planation of  these  phenomena  is  obvious  enough;  a  nodule  of 
consolidation  of  appreciable  dimensions,  but  rarely  exceed- 
ing a  walnut  in  size,  becomes  uniformly  caseous,  and  then 
softens  in  its  centre  and  gradually  liquefies  throughout  before 
communicating  with  a  bronchus,  when  its  fluid  constituents 
are  at  once  expelled,  and  auscultatory  evidence  of  the  exist- 
ence of  a  cavity  becomes  abruptly  developed.  In  the  post- 
mortem  room    we   may   often   cut   through    such   softening 


524  DISEASES  OF  THE  LUNGS   AND  PLEURA 

nodules  in  all  stages  of  ripeness  for  exit;  they  sometimes 
undermine  and  rupture  through  the  pleura,  and  may  well  be 
designated  caseous  abscesses. 

The  following  case,  alluded  to  by  one  of  us  in  a  clinical 
lecture  delivered  at  the  Brompton  Hospital,^  illustrates  the 
rapid  formation  of  a  cavity  at  the  right  apex,  and  the  cicatrisa- 
tion and  clearing  up  of  signs  and  symptoms  which  may  some- 
times follow : 

A.  W.,  a  pale,  scrofulous-looking  girl,  who  was  in  attendance  at  the 
time  of  the  lecture,  had  been  under  observation  at  the  hospital  since 
March,  1872,  when,  at  the  age  of  fifteen,  she  first  came  as  an  out- 
patient. She  had  then  a  somewhat  loud  cough,  which  had  troubled 
her  all  the  winter,  but  there  were  no  other  definite  symptoms  and  no 
discoverable  pulmonary  signs.  Her  family  history  was  good,  but  she 
had  been  delicate  since  an  attack  of  measles  in  childhood.  She 
recovered  on  ordinary  treatment,  but  returned  in  October,  1874,  and 
again  improved,  but  was  ailing  during  the  winter.  In  the  spring  of 
1875  her  principal  complaint  was  of  a  painful  affection  of  the  left 
breast ;  she  still  had  no  definite  pulmonary  signs  or  symptoms  beyond 
general  delicacy  and  slight  cough. 

In  June  she  had  whooping-cough  rather  severely ;  and  six  weeks 
after  she  still  whooped  with  the  cough,  which  was  attended  with  thick, 
difficult  expectoration.  On  again  examining  her  chest,  one  was 
somewhat  surprised  to  find  dulness,  with  marked  cavernous  breathing 
and  some  gurgling  below  the  right  clavicle ;  moist  crepitant  rales  were 
also  rather  sparsely  scattered  over  the  posterior  base.  Fever  and 
hectic  symptoms  were  now  marked.  The  prognosis  appeared  grave, 
and  she  was  recommended  to  obtain  an  in-patient's  letter.  She  did 
not  come  into  the  hospital,  howevei,  until  January,  1876,  and  mean- 
while improved  as  an  out-patient.  In  the  preceding  October  no  moist 
sounds  were  audible,  and  on  admission  into  the  ward  in  January  her 
chest  was  examined  with  great  care,  and  on  several  subsequent 
occasions,  but  nothing  beyond  some  harshness  and  feebleness  of 
breathing  at  the  right  apex  could  be  discovered. 

After  leaving  the  hospital  in  1876  she  remained  well  for  a  consider- 
able time,  and  early  in  1883  was  married.  In  the  course  of  that  year 
she  had  a  miscarriage,  and  afterwards  suffered  much  from  menor- 
rhagia.  In  May,  1885,  she  again  came  under  observation,  with  cough, 
especially  during  the  night  and  in  the  morning,  and  some  loss  of  flesh. 
She  was  nursing  entirely  a  child  eight  months  old.  At  the  right  apex, 
the  seat  of  former  mischief,  there  was  slight  dulness  and  some  deep 
crackling  and  catarrhal  rales,  but  no  evidence  of  a  cavity.  A  few 
bronchitic  rales  were  scattered  over  the  chest  on  both  sides.  The 
breath-sounds  below  the  left  apex  were  not  quite  satisfactory.  Shortly 
after  this  she  ceased  to  attend,  and  was  lost  sight  of. 


TUBERCULOUS   EXCAVATION  OF  THE  LUNG  525 

This  case  would  appear  to  have  been  one  of  solitary  caseous 
abscess  at  the  right  apex,  the  contents  of  which  were  exper- 
torated,  cicatrisation  of  the  resulting  cavity  then  ensuing,  in 
a  manner  analogous  to  that  sometimes  seen  in  suppurating 
glands  of  the  neck.  It  may  be  urged  that  as  tubercle  bacilli 
were  not  found — the  date  of  the  observation  precluding  this 
— the  case  must  remain  a  doubtful  one ;  but  its  subsequent 
course  supports  the  diagnosis,  and  we  have  since  observed 
a  very  similar  case  in  private,  in  which  bacilli  were  discovered, 
and  which  we  will  now  very  briefly  relate. 

A  gentleman,  aged  about  twenty-five  years,  was  at  a  French 
watering-place,  and  on  the  night  of  his  departure  was  dancing  to  a 
late  hour,  and  only  allowed  himself  time  to  rush  in  evening  clothes  to 
the  boat  of  departure  for  London.  He  was  much  heated,  and  became 
severely  chilled  on  the  voyage.  The  next  day  he  was  seized  with  rigor 
and  very  severe  pain  in  the  left  upper  scapular  region.  He  presented 
the  signs  of  ac«te  pneumonia,  but  when  seen  at  Maidenhead  in  con- 
sultation with  Dr.  Moore  within  a  few  days  of  his  attack,  the  pain  in 
the  shoulder  continued,  and  there  were  notable  cavernous  breath-sounds 
and  gurgling  over  the  spinous  region  of  the  left  scapula.  The  tempera- 
ture was  high  and  fluctuating,  with  marked  night-sweating,  and  a 
considerable  amount  of  muco-purulent  expectoration  of  a  very  foetid 
odour  was  being  discharged.  In  a  word,  the  signs  and  symptoms  were 
those  of  an  abscess  in  the  upper  and  back  portion  of  the  left  lung. 
The  peculiarity  of  site  and  the  general  aspect  of  the  case  led  to  a 
careful  examination  of  the  sputum,  which  revealed  the  presence  of 
tubercle  bacilli  in  abundance.  Nevertheless,  to  be  brief,  this  gentleman 
made  a  fairly  rapid  and  complete  recovery,  and,  some  fifteen  years 
later,  had  married,  and  was  in  excellent  health,  having  since  engaged 
in  big-game  shooting  in  Africa,  and  having  effected  an  insurance  on 
his  life  at  ordinary  rates. 

The  case  is  a  modern  analogue  to  the  preceding  one,  and 
may  be  rightly  described  as  an  example  of  tuberculous  abscess 
of  the  lung.  Similar  cases  have  also  been  reported  by  other 
observers,  and  post-mortem  observation  leaves  little  doubt 
that  such  abscesses  occur  more  frequently  than  positive  clinical 
experience  would  indicate,  although  they  are  rarely  single  and 
uncomplicated,  as  in  the  above  instances. 

It  should  be  especially  added  that  when  a  second  attack 
occurs  it  often  does  not  affect,  as  in  the  case  of  A.  W.,  the 
part  of  the  lung  originally  attacked,  but  some  other  portion 
of  the  same  lung  or  the  opposite  apex. 

With  the  softening  of  the  pulmonary  textures  the  expec- 


526  DISEASES   OF  THE  LUNGS   AND   PLEURA 

toration  ceases  to  consist  of  mucus.  It  is  no  longer  viscid, 
tenacious,  and  more  or  less  frothy,  but  contains  opaque  specks 
and  purulent  streaks,  and,  gradually  becoming  more  purulent, 
each  sputum  is  moulded  in  its  escape  through  the  air-passages 
and  clothed  with  a  thin  layer  of  mucus  to  form  a  more  or  less 
isolated  nummular  mass.  With  the  enlargement  of  the 
cavities  the  sputum  becomes  more  diffluent.  As  the  expec- 
toration increases  in  abundance,  it  becomes  also  easier,  and 
the  patient  describes  his  cough  as  being  looser,  but  soon 
complains  of  the  amount  of  expectoration. 

At  an  early  period,  when  the  centres  of  excavation  are  as 
yet  minute,  a  careful  examination  of  the  sputum  (p.  72)  will 
reveal  the  presence  of  elastic  tissue  (Fig.  55),  which  has  in- 
deed almost    exactly  the   same   significance  as   that  of  the 


Fig.    55. — Elastic    Tissue    from    Phthisical    Sputum.      Woodcuts    from 
photographs  taken  by  the  late  Mr.  F.  Fowke.       x  170  (about). 

physical  sign  of  moist  crackling.     Tubercle  bacilli  are  at  this 
stage  always  present,  and  generally  in  abundance. 

A  cavity  of  recognisable  dimensions  having  been  formed, 
it  may  increase  indefinitely  by  solution  of  fresh  tissue  and  by 
the  coalescence  with  it  of  smaller  cavities;  or  it  may  cease  to 
extend.  In  the  latter  case  it  may  continue  to  secrete  much 
purulent  fluid  for  a  long  time,  or  it  may  become  quiescent  and 
undergo  more  or  less  contraction.  The  ordinary  method  of 
extension  and  enlargement  of  cavities  by  softening  down  of 
fresh  pulmonary  tissue  into  the  original  cavity,  and  by  the 
merging  of  adjacent  smaller  excavations  into  one  larger  one, 
requires  no  further  comment.  It  is  obvious  that  all  trabecu- 
lated  cavities  have  been  formed  in  this  way,  the  trabeculae 
being  the  remnants  of  the  septa  which  formerly  partitioned 
the  smaller  cavities  from  one  another. 


TUBERCULOUS   EXCAVATION  OF  THE  LUNG  527 

There  is,  however,  another  theory,  advanced  by  the  late 
Professor  Rindfleisch,-  to  explain  the  enlargement  of  bronchial 
and  other  cavities,  which  we  must  notice  here,  although  there 
are  many  and  important  objections  to  its  acceptance.  Accord- 
ing to  this  theory,  the  obstruction  of  numerous  small  bronchi 
by  the  pulmonary  consolidations  necessitates  during  inspira- 
tion an  increase  of  the  air-pressure  upon  the  interior  of  the 
bronchi  in  front  of  the  obstruction,  and  also  upon  the  interior 
of  cavities,  thus  leading  to  their  dilatation. 

Professor  Rindfleisch  conceived  that  the  soft  walls  of  recent 
cavities  readily  yield  before  this  increased  air-pressure,  and 
thus  enlarge  towards  the  pleural  surface,  condensing  the  tissue 
around  them.  When  we  consider,  however,  that  the  influx  of 
air  into  the  lungs  does  not  take  place  in  any  constant  quantity, 
but  awaits  the  aspiration  dependent  upon  the  expansion  of 
the  thoracic  cavity,  we  see  that  this  theory  cannot  apply  to 
the  enlargement  of  phthisical  cavities  nor  even  to  ordinary 
cases  of  bronchiectasis.  For  in  both  these  morbid  states,  but 
especially  in  phthisis,  the  lung  is  more  or  less  consolidated  or 
thickened,  and  having  its  pleural  surfaces  adherent,  at  least 
over  those  portions  which  are  excavated,  resists  expansion 
more  than  in  health.  In  vigorous  people  with  healthy  lungs 
the  utmost  available  inspiratory  force  only  exceeds  by  from 
two  to  three  inches  of  mercury  that  necessary  to  expand  the 
lung.  In  phthisis  this  reserve  force  is  much  diminished,  and 
the  vital  capacity  of  the  chest  much  lessened,  so  that  we  have 
less  air  entering  the  lungs  and  at  less  pressure.  Hence  it 
would  seem  that  the  inspiratory  force,  effective  in  producing 
certain  forms  of  emphysema,  can  have  but  little  appreciable 
action  in  dilating  pulmonary  cavities.  We  have  not  observed 
in  phthisis,  except  in  advanced  cases  with  marked  dyspnoea, 
any  excessive  effort  with  inspiration ;  the  muscles  of  inspira- 
tion, indeed,  lessen  in  vigour  with  the  general  wasting. 
During  cough,  however,  the  intercostal  spaces  over  a  super- 
ficial cavity  become  noticeably  bulged,  and  with  the  stetho- 
scope we  may  hear  the  air  forcibly  rushing  into  the  cavity,  so 
that  doubtless  the  repeated  cough  has  a  tendency  to  dilate 
cavities  somewhat,  though  even  this  is  only  an  auxiliary  force 
in  effecting  their  enlargement. 

The  temperature  chart  of  a  case  of  phthisis  with  recently 
formed  and  extended  cavities  depicts,  as  we  have  seen,   a 


528  DISEASES   OF  THE  LUNGS  AND   PLEURA 

markedly  hectic  type  of  fever  (Fig.  46,  p.  478).  The  tempera- 
ture mounts  up  to  a  considerable  height,  from  101°  to  103° 
in  the  course  of  some  hours  during  the  day,  the  maxi- 
mum being  usually  attained  at  some  period  between 
2  p.m.  and  10  p.m.  From  this  point  a  fall  ensues  to  below 
the  normal,  the  subnormal  curve  culminating  usually  towards 
the  early  hours  of  the  morning.  The  range  of  temperature 
is  sufificiently  indicated  for  clinical  purposes  by  observations 
taken  two  or  three  times  a  day,  provided  we  are  careful  to 
note  the  period  of  the  day  at  which  the  fever  is  highest,  and 
to  record  a  daily  observation  at  that  time.  We  must  be 
further  careful  to  remember  that  a  normal  morning  tempera- 
ture means,  in  these  febrile  cases,  a  subnormal  early  morn- 
ing temperature,  as  this  has  an  important  bearing  upon 
treatment. 

In  a  certain  number  of  cases  cavities,  and  especially  those 
having  their  origin  in  caseous  abscesses,  cicatrise  and  become 
obliterated.  Laennec  described  this  as  the  natural  mode  of 
healing,  and  seemed  to  regard  phthisis  as  incurable  in  the  first 
stasre  of  the  disease.  Taking  the  term  cavity  in  its  strict  sense 
as  meaning  any  loss  of  pulmonary  substance,  however  small, 
cicatrisation  is  probably  common;  nay,  we  find  post-mortem 
evidence  of  the  cicatrisation  of  cavities  large  enough  to  come 
within  clinical  recognition,  but  they  may  be  surrounded  by 
other  cavities  and  disease  centres,  which  continue  to  enlarge 
and  render  cicatrisation  of  one  amongst  them  of  little  avail. 
We  have,  however,  alluded  to  a  case  in  which  a  caseous  cavity 
formed  and  cicatrised  under  observation,  the  patient  remain- 
ing well  for  more  than  fifteen  years  afterwards. 

2.  Quiescent  Cavity. — It  more  commonly  happens  that  a 
cavity,  having  attained  certain  dimensions,  becomes  quiescent, 
all  progress  of  the  pulmonary  disease  being  arrested;  its  walls 
then  condense  and  toughen  by  the  development  of  fibrous 
tissue,  so  as  to  shut  it  off  from  the  surrounding  lung.  The 
contents  of  the  cavity  become  less  and  less  abundant,  the 
sounds  yielded  to  auscultation  more  and  more  dry,  until  no 
moist  sounds  at  all  are  heard  even  on  deep  breathing,  but  only 
a  few  clicks  and  a  characteristic  succussion  of  air  when  the 
patient  coughs.  This  kind  of  cavity  at  once  begins  to  shrink 
somewhat  in  size,  its  walls  becoming  denser  and  thicker  by  a 
cicatricial  process   (Plate   XXX.);   the   corresponding  chest 


PLATE  XXX 


ARRESTED  TUBERCULOSIS  WITH  TOTAL 
EXCAVATION  OF  LUNG 

The  drawing  shows  a  vertical  section  through  the  left  lung, 
the  parts  being  then  opened  out.  The  whole  of  this  lung  is  now 
represented  by  the  cavity  seen,  which  measured  three  inches  in 
length,  two  inches  in  breadth.  Into  this  open  the  two  main 
divisions  of  the  left  bronchus,  the  positions  of  which  are  indi- 
cated b}'  the  glass  rods.  The  cavity  had  greatly  shrunken  and 
become  "  quiescent."  The  pleura  over,  it  is  dense  and  much 
thickened. 

From  a  boy  aged  eighteen,  who  was  admitted  into  the  Brornp- 
ton  Hospital  suffering  from  acute  bronchitis,  and  who  died  of 
the  same  four  days  later.  The  left  side  of  his  chest  was  greatly 
fallen  in,  and  the  heart  was  much  drawn  over  to  the  left.  The 
right  lung  was  enlarged,  and  showed  evidence  of  former  tuber- 
culous disease.  At  the  autopsy  evidence  of  acute  bronchitis  was 
found,  but  none  of  active  tuberculosis. 


(From  the  Brompton  Hospital  Museum.     Actual  size.) 


PLATE  XXX 


Arrested  Tuberculosis  with  Total  Excavation  of  Lung. 


To  face  p.  52S. 


TUBERCULOUS   EXCAVATION  OF  THE  LUNG  529 

wall  flattens,  and  the  heart  and  opposite  lung  encroach  towards 
the  affected  side,  to  make  up  for  the  loss  of  space.  If  the 
surrounding  lung  be  tolerably  sound  it  will  become  expanded 
around  the  cavity,  so  that  the  latter,  if  only  of  moderate  size 
and  not  very  superficial,  may  become  altogether  obscured. 
It  is  very  common  post-mortem  to  see  a  longitudinal  fold  or 
wrinkle  upon  the  surface  of  the  lung  bounded  by  expanded 
vesicular  tissue,  and  on  making  a  vertical  section  through 
such  a  wrinkle,  we  cut  across  a  more  or  less  deeply  seated  cavity 
which  has  evidently  undergone  contraction  or  possibly  cicatris- 
ation. Even  superficial  cavities  may  become  in  this  way  lost 
to  clinical  observation.  There  are  in  the  Brompton  Hospital 
Museum  some  examples  of  such  a  condition,  which  is  well 
but  rudely  depicted  in  Laennec's  work.^ 

That  even  large  cavities  may  cicatrise  and  become  per- 
manently  obliterated  is  a  fact  ascertained,  as  we  have  seen 
both  by  clinical  and  post-mortem  observation,  although  its 
occurrence  is  no  doubt  rare.  It  is,  however,  quite  common 
for  the  physical  signs  of  a  cavity  which  has  undergone  a 
certain  degree  of  contraction  to  disappear,  and  be  replaced  by 
simply  suppressed  or  very  feeble  (conducted)  breath-sound. 
This  does  not  necessarily  arise  from  the  cavity  becoming 
obHterated,  but  from  the  bronchus  with  which  it  communi- 
cates becoming  narrowed  or  occluded  by  the  dense  cicatricial 
growth  in  the  cavity  wall,  in  which  the  sheath  of  the  bronchus 
partakes.  Such  a  cavity,  although  it  may,  perchance,  com- 
municate with  a  few  collateral  minor  bronchial  tubes,  is  practi- 
cally or  completely  closed,  and  this  is  the  next  best  thing  to 
its  being  obliterated.  It  diminishes  in  size,  and  ceases  to  take 
any  further  part  in  the  production  of  pulmonary  symptoms. 

In  this  period  of  cicatrisation  tubercle  bacilli  are  present  in 
greatly  diminished  numbers,  or  may  be  altogether  absent,  un- 
less there  be  other  excavations  or  tuberculous  lesions  present 
which  are  less  quiescent. 

We  have  observed  clinically  the  complete  loss  of  all  signs 
over  a  cavity  of  considerable  size,  and  their  return  after  a  few 
days,  showing  that  a  temporary  closure  of  the  bronchus  had 
taken  place,  probably  from  a  plug  of  mucus.  The  periodically 
abundant  and  foetid  expectoration  found  in  some  cases  in 
which  there  can  be  discovered  no  signs  of  excavation  is  due 
to  the  cavity  only  communicating  obliquely  with  a  bronchus, 

34 


530  DISEASES   OF  THE  LUNGS   AND  PLEURA 

SO  that  the  secretion  becomes  pent  up  for  some  time  before  it 
can  find  an  exit. 

3.  Secreting  Cavity. — This  is  usually  a  cavity  of  tolerably 
old  date  which  has  ceased  to  extend,  and  is  unaccompanied  by 
active  pulmonary  disease.  It  is  dense-walled,  and  is  lined  by 
a  smooth  opaque  pyogenic  (false)  membrane,  which  can  be 
readily  scraped  off,  exposing  a  hig'hly  vascular,  dusky  red,  sub- 
jacent surface.  The  trabeculae,  which  are  numerous,  present 
the  same  vascular  surfaces  and  false  membranes.  Such  cavities 
may  go  on  indefinitely  secreting  a  diffluent  creamy  pus;  they 
yield  gurgling  sounds,  with  marked  amphoric  breathing,  and 
dull  tubular  percussion  note.  There  is  either  no  fever,  or  it 
is  trivial,  consisting  of  a  slight  rise  of  temperature  only  at 
night.  The  tongue  is  clean,  with  a  tendency  to  redness  and 
loss  of  epithelium.  Although  the  appetite  usually  continues 
good,  the  patient  slowly  loses  ground,  and  acquires  the  sharp 
hungry  features  peculiar  to  chronic  phthisis,  with  clubbing  of 
the  fingers  and  toes,  and  a  tendency  to  lardaceous  degenera- 
tion of  organs.  Diarrhoea  is  apt  to  supervene,  and  trouble- 
some sickness  is  sometimes  occasioned  by  the  cough.  These 
cases  are  serious,  but  are  less  common  now  than  formerly. 

In  favourable  cases  the  secretion  dries  up  and  the  cavity 
becomes  quiescent.  Unfavourable  cases  gradually  fail  from 
lardaceous  disease  of  other  organs  or  from  recurrent 
diarrhoea.  Also  there  is,  in  these  cases  especially,  the  danger 
of  some  of  the  abundant  secretion  becoming  inhaled  during 
cough  into  portions  of  the  same  or  of  the  opposite  lung  as  yet 
unaffected,  and  thus  setting  up  fresh  centres  of  disease. 

Haemoptysis  is  not  common  from  either  the  quiescent  or 
the  secreting  cavity,  but  it  sometimes  occurs  in  a  dangerous 
and  unexpected  manner  from  the  rupture  of  an  ectasia  or 
aneurismal  dilatation  projecting  from  the  unsupported  cavity 
side  of  a  large  pulmonary  vessel. 

4.  Ulcerous  Cavity. — This  last  kind  or  condition  of  cavity, 
which  is  also  more  rarely  met  with  in  these  days  of  aseptic 
treatment,  originates  in  the  usual  way,  and  may  have  been 
quiescent  or  merely  secreting"  for  some  time,  when,  from  ex- 
posure to  septic  influences,  or  from  other  causes,  it  assumes 
a  state  of  active  ulcerative  extension.  We  have  known  such 
cases  to  be  endemic  in  a  ward  which  was  overcrowded,  and  to 
have  ceased  on  a  bed  being  removed.     It  cannot,  indeed,  be 


TUBERCULOUS  EXCAVATION  OF  THE  LUNG      53 1 

too  carefully  remembered  in  the  treatment  of  tuberculous 
affections  of  the  lungs  that  all  such  patients  have  internal 
wounds  or  sores,  which,  unlike  most  other  internal  affections, 
are  accessible  to  the  contamination  of  foul  air,  and  that  septic 
processes  may  be  readily  set  up  in  them,  which  are  apt  to  be 
recognised  only  as  "intercurrent  pneumonias^'  or  other  local 
inflammations. 

Ulcerous  cavities  are  angry-looking,  deep  dusky  red  on  their 
inner  surfaces,  often  studded  with  hgemorrhagic  points  or 
ulcerative  erosions;  they  are  highly  trabeculated  and  very 
irregular  in  shape,  but  sharply  demarcated  from  the  lung 
tissue  by  a  thin  vascular  wall.  They  contain  a  copious  blood- 
stained purulent  secretion,  which,  when  expectorated,  is  mixed 
with  the  ropy  mucus  from  the  intensely  vascular  bronchi  which 
communicate  with  them.  The  lung  tissue  surrounding  the  cavity 
is  eng-orged  and  oedematous,  and  at  distant  parts  of  the  lungs 
pneumonic  centres  may  be  found,  which  evidently  owe  their 
origin  to  the  inhalation  of  the  acrid  secretions  from  the  cavity. 
In  such  cases  sharp  fever  is  present,  with  quick  pulse,  furred 
tongue,  and  a  tendency  to  typhoid  symptoms.  The  expectora- 
tion is  usually  mixed  with  blood,  or  dark  altered  clots  may  be 
removed  from  the  cavity.  Sometimes  copious  haemorrhage 
takes  place  from  the  erosion  of  a  large  vessel. 

The  prognosis  in  cases  of  ulcerous  cavity  is  always  grave 
and  hazardous,  but  if  it  be  borne  in  mind  that  the  aggrava- 
tion of  symptoms  is  to  be  explained  rather  by  insanitary  con- 
ditions surrounding  the  patient  than  by  an  accession  of 
genuine  tuberculous  activity — in  other  words,  that  the  condi- 
tion is  septic  rather  than  tuberculous — an  appropriate  measure 
of  treatment  corresponding-  to  this  view  will  often  consider- 
ably amend  the  prospects  of  the  patient. 

The  treatment  of  these  conditions  will  be  dealt  with  in  a 
later  chapter  (p.  688). 

REFERENCES. 

'  "  Clinical  Lectures  on  Excavation  of  the  Lung  in  Phthisis,"  by  R. 
Douglas  Powell,  M.D.,  Lecture  IL,  The  Lancet';  1877,  vol.  i.,  p.  119. 

^  "  Chronic  Tuberculosis  —  Phthisis,"  by  Professor  Rindfleisch. 
Ziemssen's  Cyclofadia  of  the  Practice  of  Medicine,  vol.  v.,  p.  679. 
London,   1875.' 

^  Traite  de  V Auscultation  mediate  et  des  Maladies  des  Poumons  et  du 
Coeur,  par  R.  T.  H.  Laennec,  troisieme  edition,  tome  iii.,  planche  ii., 
Fig.  4.     Paris,  1831. 


CHAPTER  XXXVII 

THE   COMPLICATIONS   OF   PULMONARY  TUBERCULOSIS 

Laryngeal,  Aural,  and  Intestinal  Tuberculosis. 

The  complications  met  with  in  the  course  of  tuberculosis  of 
the  lungs  are  many  and  varied.  The  relative  frequency  of 
the  most  important,  as  deduced  from  the  autopsies  of  263 
consecutive  cases  (188  males,  75  females)  of  chronic  pul- 
monary tuberculosis,  in  which  the  post-mortem  examinations 
were  made  by  one  of  us,  is  shown  in  the  following  table : 

Table  showing  Relative  Frequency  of  the  More  Important  Complica- 
tions OF  Chronic  Pulmonary  Tuberculosis,  based  upon  263  Con- 
secutive Autopsies  (188  Males,  75  Females). 


Males. 

Females. 

Total. 

Per  Cent. 

Per  Cent 

Per  Cent. 

Larynx— tuberculous  ulceration  of      « 

547 

469 

52*6 

Trachea- 

27-1 

200 

25-1 

Main  bronchi —   ,,              ,, 

12-2 

io"6 

II-4 

Pneumothorax             

7 '4 

4-0 

6-4 

Pleurisy— (i)  acute  sero-fibrinous 

6-3 

4-5 

(2)  suppurative  (empyema) 

2'I 

2-6 

2-2 

Pulmonary  aneurism 

10 '6 

5-3 

g-i 

Fatal  haemoptysis                   

9-0 

4-0 

7-6 

Pericarditis — tuberculous      

21 

I '5 

Veins — thrombosis  of 

10 

6-6 

2-6 

Peritonitis — tuberculous        

37 

2-6 

34 

Intestines — tuberculous  ulceration  of 

61 -3 

6i-3 

61 -3 

Fistula  iw  a«o 

1-6 

II 

Lardaceous  disease  of  viscera 

9  "5 

i3'3 

IO-6 

Kidneys — (i)  miliary  tuberculosis  of 

ii-i 

9'3 

io'6 

(2)  ulcerative  tuberculosis  of     ... 

2-6 

I '3 

2-3 

Suprarenals — tuberculous  disease  of 

2-1 

2-6 

2-3 

Bladder — tuberculous  cystitis          

i-o 

— 

07 

Male      generative      organs  —  tuberculous 

disease  of 

47 

— 

affecting  (i)  body  of  testicle     

I"0 

— 

(2)  epididymus            

3-2 

— 

—  " 

(3)  vesiculae  seminales          ... 

2-6 

— 

• — 

(4)  prostate      

3-2 

— 

• — 

'  Female     generative      organs — tuberculous 

disease  of 



io'7 

— 

affecting  (i)  ovaries        

— 

27 

— 

(2)  Fallopian  tubes 

— 

loy 

— 

(3)  endometrium         

— 

6-7 

— 

Meningitis — tuberculous        

2-6 

2-6 

2-6 

532 


THE   COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      533 

Let  us  now  consider  some  of  the  above  complications  in 

more  detail. 

Laryngeal  Tuberculosis. 

It  sometimes  happens  in  the  adult  that  pulmonary  tubercu- 
losis is  ushered  in  with  laryngeal  symptoms,  and  the  variety 
of  the  disease  thus  arising  ranks  amongst  the  most  fatal  and 
distressing  of  all. 

Strictly  speaking,  the  term  "  laryngeal  phthisis  "  should  be 
applied  only  to  those  very  rare  cases  in  which  the  tuberculous 
lesion  of  the  larynx  is  primary;  but  in  practice  it  is  more 
loosely  employed  to  include  all  those  cases  in  which  laryngeal 
symptoms  constitute  an  early  and  striking  feature.  This  latter 
employment  of  the  term  is  not  only  more  convenient,  but  is 
also  more  in  accordance  with  the  general  pathology  of  the 
disease;  for  althoug'h  in  many  instances  it  is  the  affection  of 
the  larynx  which  first  attracts  attention,  yet  even  in  these 
cases  the  lungs  speedily  show  obvious  involvement,  so  that 
to  attempt  more  rigidly  to  restrict  the  term  would  imply,  what 
is  not  the  fact,  that  there  is  a  phthisis  which  begins  and  ends 
with  laryngeal  disease. 

In  the  analysis  of  our  consecutive  autopsies  upon  cases  of 
chronic  pulmonary  tuberculosis,^"  in  247  of  which  the  larynx 
was  examined,  we  found  naked-eye  evidence  of  involvement 
of  the  larynx  in  130,  or  52'6  per  cent.;  in  89  cases,  or  360  per 
cent.,  the  ulceration  was  "  extensive."  Probably  the  latter 
figures  represent  more  nearly  the  percentage  of  cases  in  which 
symptoms  referable  to  the  larynx  are  complained  of  during 
life.  The  sexes  would  appear  to  be  affected  equally,  but  it  is 
remarkable  how  exceedingly  uncommon  the  complication  is  in 
children. 

The  following  table,  based  upon  our  247  autopsies,  shows 
certain  further  points  of  interest  in  regard  to  the  condition : 

Table  showing  the  Lesions  met  with  in  the  Larynx  after  Death  in 
247  Cases  of  Chronic  Pulmonary  Tuberculosis. 


Larnyx — Tuberculous  ulceration,  total  cases 
Slight  ulceration 
Extensive  ulceration 

,,         laying  bare  left  arytenoid  ... 
,,  ,,         ,,      right  arytenoid 

,,  ,,         ,,      the  thyroid 

,,         destroying  upper  portion  of 

epiglottis  

OEdema  of  glottis  


Number  of 

Cases 
Affected. 

Percentag 

130 

4i\ 
89/ 

526 

i6-6\ 

360/ 

30 

121 

20 

81 

I 

0-4 

18 

70 

3 

12 

534  DISEASES   OF   THE   LUNGS   AND   PLEURA 

Tuberculous  disease  of  the  larynx  most  commonly  arises 
as  a  complication  in  advanced  pulmonary  phthisis.  It  is,  how- 
ever, by  no  means  restricted  to  such  cases,  and  it  has  been 
shown  at  the  King  Edward  VII.  Sanatorium,  Midhurst,  by 
Sir  StClair  Thomson,-  that  even  in  the  early  cases  included  in 
Group  I.  137  per  cent,  showed  evidence  of  laryngeal  involve- 
ment, the  percentag-e  rising  to  27' i  among  the  patients  in 
Group  II.,  and  to  408  in  Group  III. 

The  way  in  which  the  larynx  becomes  affected  has  been 
much  debated,  but  there  can  be  little  doubt  that  it  is  the  result 
of  direct  contact  of  the  sputum  with  the  mucous  membrane, 
the  expectoration  tending  to  cling  to  any  crannies  and  crevices 
that  it  meets  with  in  its  passage  outwards.  The  bacilli 
possibly  sometimes  enter  the  laryngeal  tissue  through  super- 
ficial erosions,  or  pass  through  the  unbroken  mucous  mem- 
brane, as  in  the  case  of  the  intestinal  wall.  But  Dr.  Jobson 
Horne^  has  demonstrated  that  they  may  enter  through  another 
portal,  the  ducts  of  the  muciparous  glands  of  the  submucosa; 
and  very  probably  this  is  the  most  common  mode  of  entrance, 
since,  as  he  points  out,  the  parts  of  the  larynx  richest  in 
glandular  structures,  such  as  the  arytenoid  eminences,  and 
especially  the  interarytenoid  region,  are  also  those  most 
vulnerable  to  tuberculous  infection. 

The  bacilli  having  gained  access  to  the  larynx,  the  progress 
of  the  disease  is  similar  to  that  in  other  organs.  Tubercles 
form  in  the  submucosa,  producing  tumefaction  and  oedema. 
Later,  caseation  and  softening  occur,  with  the  production  of 
minute  ulcers,  which,  by  their  coalescence,  form  larger  ones, 
the  floors  and  walls  of  which  are  the  seat  of  fresh  tuberculous 
deposits. 

The  morbid  appearances  seen  with  the  laryngoscope  during 
life  vary  according  to  the  period  of  the  disease.  In  the  early 
stage  a  marked  and  general  anaemia  of  the  laryngeal  mucous 
membrane  is  often  present,  which,  if  it  does  not  form  part  of 
a  general  anaemia,  should  be  regarded  as  very  suggestive  of 
tubercle.  In  other  cases  the  larynx  is  hyperaemic.  Later,  as 
the  tubercles  enlarge,  infiltration  and  oedema  become  visible 
to  the  naked  eye.  The  positions  in  which  these  appearances 
are  first  seen  differ.  Our  own  experience  would  lead  us  to 
place  the  first  signs  in  the  interarytenoid  space  or  in  the 
aryepiglottic  folds,  and  this  is  in  accordance  with  the  experi- 


THE   COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      535 

ence  of  Dr.  Home/  who,  in  a  careful  analysis  of  359  consecu- 
tive cases  of  pulmonary  tuberculosis,  found  that  the  parts  were 
affected  in  the  following  order : 

Interarytenoid  space               ...  ...  ...  in  176  cases. 

Arj'tenoid  eminences  (bilaterally)  ...  ...  ,,  139      ,, 

Ventricular  bands   (bilaterally)  ...  ...  ,,  57      ,, 

Epiglottis  (free  edge)             ...  ...  ...  ,,  30      ,, 

The  early  changes  which  thus  present  themselves  in  the 
interarytenoid  space,  and  which  are  so  important  from  a 
diagnostic  point  of  view,  are  perhaps  hardly  as  yet  sufficiently 
appreciated.  They  may  consist  merely  of  a  slightly  irregular 
swelling  of  the  mucous  membrane,  resulting  from  the  deposi- 
tion of  tubercle  beneath;  but  in  the  majority  of  cases  the 
swelling  is  more  marked,  and  in  a  few,  definite  tuberculous 
tumours  will  be  found,  pale  and  with  irreg'ular  edges,  which 
constitute  perhaps  the  only  evidence  of  laryngeal  tuberculosis. 

As  the  oedema  increases,  characteristic  changes  may  be 
produced,  the  swelling  over  the  arytenoids  and  in  the  ary- 
epiglottic  folds  presenting  the  well-known  "  pear-shaped  "  ap- 
pearance, while  the  epiglottis  may  become  pale  and  swollen, 
or,  as  it  has  been  termed,  "  turban-shaped." 

Ulceration  later  supervenes,  the  favourite  seat  being  over 
the  glottic  aspect  of  the  arytenoid  cartilages,  where  a  ragged 
ulcerous  hole  is  often  found,  at  the  bottom  of  which  after 
death  the  denuded  and  roughened  cartilage  may  sometimes  be 
felt.  The  interarytenoid  space,  the  ventricular  bands,  the 
vocal  cords  and  epiglottis  are  also  frequently  the  seat  of 
ulceration,  and  we  have  seen  instances  in  which  ulceration  has 
extended  deeply  from  the  anterior  junction  of  the  vocal  cords 
to  produce  perichondritis  of  the  thyroid  cartilage  with  involve- 
ment of  the  subcutaneous  cellular  tissue.  Ulceration  in  the 
more  deeply  seated  parts  may  or  may  not  be  observed  by  the 
laryngoscope,  but  intense  injection  of  the  mucous  membrane 
is  often  visible.  In  advanced  cases  the  orifice  of  the  glottis 
may  be  seen  distorted  by  ulceration  and  thickening,  the  cords 
being  involved  in  the  havoc  so  as  to  render  their  approxima- 
tion impossible,  and  the  arytenoid  articulations  on  one  or 
both  sides  participating  in  the  disease.  In  this  stage,  purulent 
secretion  collects  in  the  ventricles  and  about  the  cords. 

With  severe  ulceration  of  the  larynx,  it  is  common  to  find 
a  similar  condition   of  the   trachea,  and   less  often   of  the 


536  DISEASES   OF  THE  LUNGS   AND  PLEUR/E 

bronchi.  In  the  trachea  the  ulceration  tends  to  spread  from 
minute  points,  and  gives  a  pecuHar  moth-fretted  appearance 
to  the  surfaces.  In  other  cases  the  ulcers  are  larger,  and 
frequently  surrounded  by  a  brilliant  red  zone  of  injection; 
eventually  the  tracheal  cartilages  are  often  laid  bare. 

Symptoms.  —  The  sufferings  of  the  victim  of  larnygeal 
phthisis  are  great  and  varied.  One  of  the  first  symptoms  that 
attracts  attention  is  an  alteration  in  the  tone  and  quality  of 
the  voice.  It  becomes  husky  and  usually  deepened.  VocaHsa- 
tion  is  uncertain,  the  voice  sometimes  falling  into  a  husky 
whisper,  to  reappear  with  deep,  reverberating  tone  when  an 
increased  effort  is  made  in  speaking.  In  some  cases,  however, 
even  at  the  earliest  stage,  the  voice  is  suppressed  from  an  in- 
ability to  approximate  the  cords.  This  may  be  due  to  general 
loss  of  muscular  and  nervous  tone,  or  may  result,  as  Dr.  Home 
has  shown,  from  an  inflammation  of  the  laryngeal  muscles,  a 
myositis,  which  impedes  their  functional  activity.  In  less  early 
stages,  again,  it  may  possibly  be  mechanical,  the  result  of 
the  presence  of  a  tuberculoma  in  the  interarytenoid  space, 
such  as  we  have  described,  or  in  rare  cases  arising  from  com- 
pression of  one  or  other  recurrent  laryngeal  nerve,  the  right, 
as  a  rule,  from  apical  pleurisy,  the  left  by  enlarged  and 
probably  tuberculous  glands. 

If  the  laryngeal  disease  be  only  slight,  and  the  patient's  lung- 
trouble  be  quiescent  or  show  signs  of  healing,  there  may  be 
no  other  symptoms,  and,  with  suitable  treatment,  including 
absolute  rest  to  the  voice,  the  laryngeal  as  well  as  the 
pulmonary  disease  may  become  arrested.  Sir  StClair 
Thomson^  estimated  at  the  King  Edward  VII.  Sanatorium 
that  arrest  of  the  laryngeal  disease  was  obtained  in  one-fifth 
(20'7  per  cent.)  of  the  cases.  But,  encouraging  though  this  is 
there  can  be  no  question  that  the  prognosis  in  phthisis,  at 
whatever  stage  of  the  disease,  is  rendered  much  more  grave 
by  the  presence  of  the  complication,  the  mortality  among 
such  patients  being  considerably  greater  than  in  the  case  of 
those  whose  larynx  remains  unaffected. 

As  the  disease  in  chest  and  larynx  progresses,  the 
patient's  condition  becomes  a  pitiable  one.  He  loses  flesh, 
suffers  from  sweats  and  evening  fever,  and  experiences  oppres- 
sion of  breathing,  which  may  amount  to  serious  dyspnoea,  both 
respiration  and  pulse  being  quickened,     A  troublesome  teas- 


THE   COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      537 

ing  cough  of  a  harsh,  dry  character  is  complained  of,  which 
is  attended  with  pain  and  a  sense  of  rawness  in  the  throat,  and 
with  scanty  and  difficuU  expectoration.  Pain  on  deglutition 
is  a  frequent  symptom,  and  it  is  still  more  characteristic  when 
described  as  shooting  upwards  to  the  ears,  causing  in  them 
"  pricking  sensations."  On  deep  pressure  in  the  upper 
tracheal  region  some  tenderness  is  elicited.  As  the  disease  pro- 
ceeds and  the  ulcerative  destruction  of  the  larynx  extends,  the 
aphonia  becomes  complete,  and  the  cough  most  distressing 
and  paroxysmal.  At  this  period  the  lung  disease  has  usually 
proceeded  to  excavation,  and  the  expectoration  is  more  abun- 
dant; effectual  cough  is,  however,  almost  impossible,  in  conse- 
quence of  the  patient  being  no  longer  able  to  bring  about  its 
essential  condition,  closure  of  the  glottis.  Deglutition,  is  now 
difficult  and  painful,  from  the  pharyngeal  muscles  com- 
pressing the  tender  and  swollen  parts,  and  from  the  irritable, 
stiffened,  and  often  ulcerated  epiglottis  failing  effectually  to 
guard  the  laryngeal  aperture. 

The  fauces  and  tonsils  may  be  normal  in  appearance,  but 
they  are  often  pale,  and  drier  than  natural,  with  their  small 
subcapillary  veins  too  well  marked.  The  back  of  the  pharynx 
is  frequently  granular,  even  abraded,  with  streaks  of  viscid 
mucus  adherent  to  the  surface.  The  mucous  glands  are  too 
prominent.  A  distinct  ulcer,  having  the  characteristic  raised 
irregular  margin  and  granular  ash-coloured  surface  of  the 
tuberculous  ulcer,  may  sometimes  be  seen  at  the  back  of  the 
pharynx  or  behind  one  of  the  tonsils. 

In  rare  cases  an  ulcer  appears  upon  the  tongue,  or  on  the 
inside  of  the  cheek,  especially  about  the  orifice  of  the  parotid 
duct.  Such  cases  may  suggest  syphilis,  but  are  by  no  means 
necessarily  of  this  nature,  although  careful  inquiry  on  this 
point  should  always  be  made. 

Diagnosis. — In  well-marked  cases  of  tuberculous  laryngitis 
the  diagnosis  is  not  difficult.  The  diseases  which  most  simu- 
late it  are  chronic  alcoholic  or  irritative  catarrh,  especially  that 
variety  produced  by  excessive  cigarette-smoking,  syphilitic 
disease,  and  hysterical  aphonia.  More  rarely  it  has  been  mis- 
taken for  malignant  growth. 

With  regard  to  the  first-named — the  chronic  catarrh  arising 
from  drink,  dust,  or  smoking — the  absence  of  fever,  the 
presence  of  a  definite  exciting  cause,  and  the  laryngoscopic 


538  DISEASES   OF   THE   LUNGS   AND   PLEURA 

signs  of  general  catarrh  without  local  thickening  or  ulcera- 
tion, are  usually  sufficient  to  distinguish  it  from  laryngeal 
tuberculosis.  Alcoholic  and  smoker's  catarrh  are,  moreover, 
always  associated  with  a  similar  affection  of  the  pharynx.  In 
the  absence,  however,  of  a  definite  exciting  cause,  a  catarrh 
v.'hich  does  not  speedily  clear  up  under  appropriate  treatment 
should  always  be  viewed  with  suspicion.  In  any  doubtful  case 
the  sputum  must  be  examined;  tubercle  bacilli  are  invariably 
present  in  the  tenacious,  glaiiy  mucus  expelled  in  cases  of 
tuberculous  laryngitis  which  have  proceeded  to  ulceration. 

In  syphilis,  during  the  secondary  stage,  the  larynx  may 
present  a  condition  of  catarrh,  but  the  general  symptoms  of 
the  disease  should  in  this  case  guide  the  diagnosis  aright.  In 
the  tertiary  stage  gummatous  swellings,  either  localised  or 
diffused,  may  make  their  appearance.  They  are  usually  deep 
red  in  colour,  and  soon  proceed  to  ulceration.  Such  ulcers 
are  deeper  and  more  sharply  cut  than  those  occurring  in 
phthisis ;  they  are  also  much  less  painful.  Gummata  may 
occur  in  any  portion  of  the  larynx,  whether  in  the  region  of 
the  arytenoids,  the  true  or  false  vocal  cords,  or  elsewhere; 
but  a  favourite  seat  is  the  epiglottis,  leading  to  the  extensive 
destruction  which  is  so  suggestive  of  syphilis,  although  it  may 
occur  as  the  result  of  tubercle.  Much  contortion  or  deformity 
from  cicatricial  change  should  also  lead  to  a  suspicion  of 
syphilitic  disease.  A  rapid  improvement  under  a  course  of 
iodide  of  potassium  or  salvarsan  will  assist  the  diagnosis. 

Passing  to  functional  aphonia,  it  not  infrequently  happens 
in  early  phthisis,  as  we  have  already  indicated,  that  the  voice 
from  time  to  time  is  weak  and  whispering  from  inefficient 
adduction  of  the  cords,  and  the  patient  shows  all  the  symptoms 
of  a  functional  loss  of  voice.  The  larynx  may  be  anjemic,  but 
often  presents  no  other  sign  of  tuberculosis,  although  it  is 
probable  that  in  many  cases  tubercles  have  already  formed. 
Whenever  a  patient,  therefore,  presents  symptoms  of  func- 
tional aphonia,  the  possibility  of  tuberculosis  should  be  borne 
in  mind,  especially  if  the  aspect  or  family  history  renders  such 
a  disease  likely.  The  lungs  must  be  examined  with  great  care, 
and  the  weight  and  temperature  chart  closely  observed. 

It  has  sometimes  happened  that  the  tuberculous  tumours  to 
which  we  have  referred,  and  which  are  not  by  any  means 
limited  to  the  interarytenoid  region,  have  been  mistaken  for 


THE   COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      539 

malignant  growths,  and  operated  upon  accordingly.  In  such 
cases,  if,  after  careful  examination  of  the  lungs  and  of  the 
sputum,  as  well  as  of  the  appearances  of  the  larynx  and  the 
situation  of  the  tumour,  doubt  still  remains,  a  portion  of  the 
mass  must  be  removed  for  microscopical  examination. 
Another  condition  which  may  be  sometimes  mistaken  for 
laryngeal  tubercle  is  a  warty  excrescence  from  one  or  other 
cord,  a  condition  causing  partial  aphonia  and  one  not  un- 
commonly associated  with  cough  and  pulmonary  catarrh. 
Laryngeal  examination  and  removal  of  the  growth  will  settle 
the  diagnosis  and  cure  the  symptoms. 

The  treatment  of  laryngeal  tuberculosis  will  be  considered 
in  a  later  chapter  (p.  697). 

Tuberculous  Disease  of  the  Middle  Ear. 

This  manifestation  of  tuberculosis,  though  not  uncommon 
in  infants  under  two  years  of  age,  is  rare  as  a  complication 
of  phthisis  in  the  adult,  though  we  have  met  more  than  one 
instance  of  it.  When  occurring  in  connection  with  phthisis 
it  manifests  itself  by  deafness  in  the  affected  ear,  accom- 
panied by  discharge,  but  ivithont  pain.  It  is  thus  distin- 
guished from  the  more  common  septic  variety  of  acute  otitis 
media,  in  which  earache  is  at  the  commencement  a  prominent 
feature.  On  examination  the  tympanic  membrane  is  seen  to 
be  reddened,  swollen  and  thickened,  an  index  of  a  similar 
condition  of  the  mucosa  lining  the  tympanic  cavity,  and  a 
perforation  is  often  visible.  The  discharge  is  apt  to  be 
watery  and  curdy,  and  tubercle  bacilli  may  be   found  in  it. 

The  prognosis  as  regards  hearing  in  the  affected  ear  is  poor, 
but  if  the  pulmonary  tuberculosis  becomes  quiescent  and  the 
patient's  general  health  remains  satisfactory,  the  lesion  in  the 
ear  will  probably  undergo  arrest  and  the  discharge  cease. 

Treatment  consists  in  the  employment  of  sanatorium  and 
other  methods  calculated  to  benefit  the  lung  disease  and  to 
raise  the  vitality  of  the  patient.  The  ear  should  be  care- 
fully cleansed  by  the  daily  use  of  peroxide  of  hydrogen, 
Except  when  especially  exposed  to  dust,  as  in  motoring,  the 
meatus  should  not  be  closed  with  cotton-wool,  the  fresh  air 
having  a  beneficial  action  on  the  lesion  in  the  ear,  just  as  it  has 
upon  the  lungs.^ 


540  DISEASES   OF  THE  LUNGS  AND  PLEUILE  ' 

Intestinal  Tuberculosis. 

Ulceration  of  the  bowels  is  sometimes  met  with  as  a  primary 
disease  in  young  children.  It  is  a  very  common  complication 
of  phthisis — indeed,  it  may  be  said  to  be  one  of  the  attendant 
lesions  of  the  disease.  Of  the  263  consecutive  cases  alluded  to 
in  our  table  (p.  532)  it  was  present  in  61-3  per  cent.,  both  sexes 
being  affected  equally. 

Excluding  the  appendix,  intestinal  tuberculosis  is  scarcely 
ever  met  with  in  adults  except  in  association  with  tuberculous 
disease  of  the  lungs,  and  is  commonly  due  to  the  swallowing 
of  the  infected  sputum.  It  most  usually  complicates  the  later 
stages  of  the  disease,  but  it  may,  like  laryngitis,  occur  at  an 
early  period,  at  a  time  when  pulmonary  physical  signs — always 
somewhat  masked  during-  diarrhoea — are  difficult  to  detect. 
Anything  that  tends  to  derange  the  digestion  and  the  bowels 
favours  the  occurrence  of  the  complication.  Tubercle  bacilli 
are  present  in  the  intestinal  lesions,  and  may  be  discovered  in 
the  evacuations. 

The  disease  commences  with  inflammatory  swelling  of 
certain  of  the  follicles  of  the  small  or  large  intestine.  Casea- 
tion follows,  and  the  softened  products  discharge  into  the 
intestine,  leaving  an  ulcerous  recess  behind.  Both  in  sections 
of  the  ulcerated  tissues  and  in  the  discharges  from  their 
surfaces  tubercle  bacilli  are  found. 

On  the  peritoneal  surface  of  the  bowel,  over  the  site 
of  an  ulcer  thus  established,  flakes  of  lymph  are  often 
to  be  seen,  and  inflammatory  adhesions  may  be  formed 
with  an  adjacent  coil  of  intestine.  The  outline  of  the  ulcer 
can  be  distinguished  shining  through  the  peritoneal  surface, 
and  over  its  base  granulations  of  tubercle  are  to  be  observed. 
These  granulations  are  connected  with  the  lymphatic  vessels, 
some  of  which  form  white  lines  or  streaks  over  and  about  the 
site  of  the  ulcer.  The  ulcer  is  at  first  circular  in  shape,  and 
soon  comes  to  have  the  characteristic  thickened  edge  and 
irregular  warty  base  which  distinguish  it  from  the  typhoid 
ulcer.  It  tends  to  enlarge  in  a  transverse  direction,  beyond 
the  limits  of  the  giand  follicle,  in  which  it  originated,  the  ex- 
tension following  the  direction  of  the  vessels,  and  being  deter- 
mined by  the  formation  of  tubercles  in  their  sheaths. 

Whether  the  ulcers  be  single  or  in  groups  depends  upon  the 


THE  COMPLICATIONS   OF  PULMONARY   TUBERCULOSIS      54 1 

glands,  whether  soHtary  or  agminate,  which  are  attacked. 
Peyer's  patches  are  favourite  seats  of  ulceration.  In  them 
irregular  serpentine  ulceration  arises  by  extension  and  coales- 
cence from  several  centres,  often  leaving  small  tracts  or  islets 
of  mucous  membrane  intact.  All  the  gland  follicles  of  a 
patch  are  by  no  means  necessarily  affected;  the  ulceration  may 
only  involve  a  certain  number  of  them,  extending  transversely 
to  the  mucous  membrane  beyond.  In  the  caecum,  too,  the 
ulceration  is  often  very  extensive,  the  whole  of  the  mucous 
membrane  being  eroded  for  several  inches,  with  the  exception 
of  small  islets  or  streaks  here  and  there,  which  have  escaped 
and  stand  out  prominently,  indicating  the  original  extension 
of  the  ulcerative  process  from  many  centres.  More  or  less 
general  hyperasmia  of  the  mucous  membrane,  very  variable 
in  amount  at  different  tirhes  and  in  different  places,  attends 
the  ulcerative  process.  Considerable  general  thickening  of 
the  large  intestine  is  sometimes  also  present. 

As  already  mentioned,  local  peritonitis  commonly  attends 
the  intestinal  lesion,  and  adhesions  are  frequently  formed. 
Perforation  of  the  bowel  occasionally  occurs,  sometimes  lead- 
ing to  the  escape  of  fascal  matter  and  to  general  peritonitis, 
sometimes  to  the  establishment  of  a  fistulous  communication 
between  adherent  portions  of  intestine,  and,  again,  in  other 
cases  producing  collections  of  pus  localised  by  surrounding 
adhesions.  These  processes  are  strictly  analogous  with  those 
which  occur  in  connection  with  the  pleural  surface  of  the  lungs 
in  phthisis.  Drs.  W.  S.  Fenwick  and  DodwelV  from  inspec- 
tion of  the  records  of  the  Brompton  Hospital,  found  25 
instances  out  of  2,000  cases  of  phthisis  (i"2  per  cent.)  in  which 
perforation  occurred  from  this  cause.  Our  own  post-mortem 
observations^*  gave  a  very  similar  result — viz.,  3  cases  out  of 
263  autopsies,  or  a  percentage  of  i"i,  the  perforation  in  each 
of  these  instances  occurring  in  the  ileum.  We  may  add  that 
we  have  three  times  known  general  septic  peritonitis  to  result 
from  deep  tuberculous  ulceration  of  the  bowel,  but  without 
perforation. 

The  lower  two  or  three  feet  of  the  ileum  and  the  caecum  are 
almost  invariably  the  portions  of  bowel  involved  in  tuber- 
culous disease,  but  the  ulceration  may  extend  both  above  and 
beyond  these  points  to  the  duodenum  and  the  rectum.  The 
appendix  also  is  frequently  affected,  and  tuberculous  appen- 


542 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


dicitis  is  not  of  uncommon  occurrence  as  a  primary  malady. 
The  following  table  shows  the  relative  frequency  with  which 
the  different  portions  of  the  bowel  were  attacked  in  our  series 
of  autopsies,  in  6i'3  per  cent,  of  which  tuberculous  ulceration 
of  the  bowel  was  present :  ^^ 

Table  showing  the  Relative  Frequency  with  which  Tuberculous 
Ulceration  was  found  in  Different  Portions  of  the  Bowel  in 
263  Cases  of  Chronic  Pulmonary  Tuberculosis. 


Duodenum 
Jejunum 
Ileum 
Cfficum    . . . 
Appendix 
Colon 
Rectum  ... 
Fistula  in  ano 


Number  of 
Cases. 

10 

53 

•       125 

.       114 
.         98 
•         83 

35 

3 

Percentage. 

3-8 
20-3 
47-8 
43-6 
37-5 
31-8 
13-4 


It  will  be  seen  that  the  ileum,  caecum,  and  appendix  are  the 
favourite  seats  of  ulceration.  We  may  add  that  in  109  cases, 
or  41 '7  per  cent.,  ulcers  were  found  in  both  the  small  and 
large  intestine;  in  19,  or  7"2  per  cent.,  they  were  restricted  to 
the  small  intestine;  in  24,  or  9"2  per  cent.,  to  the  large;  and 
in  8,  or  3  per  cent.,  they  were  found  only  in  the  appendix. 

Symptoms. — The  usual  symptoms  of  ulceration  of  the  intes- 
tines are  diarrhoea  and  pain  in  the  abdomen.  There  is  nothing 
at  first  which  can  be  noted  as  peculiar  in  the  character  of  the 
diarrhoea;  the  stools  are  pale  and  loose,  resembling  those  of 
ordinary  intestinal  catarrh,  and  occasioned  doubtless  by  the 
presence  of  such  catarrh.  There  may  be  some  nausea;  the 
tongue  is  furred,  with  red  tip  and  edges  and  prominent  papillae, 
and  the  patient  complains  of  thirst.  The  pain  is  usually 
referred  to  the  umbilical  region ;  it  is  of  a  colicky  nature,  and 
no  marked  tenderness  is  present  over  any  special  area  of  the 
abdomen.  There  is  notable  irritability  of  the  whole  mucous 
tract,  and  the  taking  of  food,  and  more  often  warm  drinks, 
into  the  stomach  causes  the  bowels  soon  to  act.  The  loose- 
ness is,  however,  at  this  stag"e  tolerably  amenable  to  treatment, 
and  for  a  time  the  motions  become  natural,  or  the  patient  is 
even  constipated.  Soon,  however,  a  relapse  takes  place,  and 
the  diarrhoea  is  more  obstinate  than  before.  Now  some 
decided  tenderness  may  be  felt  on  deep  palpation,  most  likely 
in  the  right  iliac  region;  the  motions  become  more  scanty, 


THE  COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      543 

some  mucus  is  passed  with  them,  a  speck  or  two  of  blood  may 
be  observed,  or  a  teaspoonful  or  more  may  escape.  Anything 
approaching  to  copious  haemorrhage  is,  however,  rare.  The 
tongue  becomes  red  and  patchy  from  loss  of  epithelium;  it 
may  present  short  transverse  fissures  on  each  side  of  the 
median  line. 

The  further  symptoms  vary  with  the  seat  of  the  principal 
ulceration.  If  this  be  limited  to  the  ileum,  the  diarrhoea  may 
for  a  long  time  be  held  in  check  by  treatment;  but  the  bowels 
are  irritable,  the  abdomen  somewhat  prominent  in  the  um- 
bilical region,  and  tender.  If  the  ulceration,  on  the  other  hand, 
has  its  principal  seat  in  the  caecum,  the  tenderness  over  that 
region  is  more  marked,  the  diarrhoea  is  difficult  to  control, 
blood  and  mucus  are  frequently  present  in  the  stools,  and  the 
patient  acquires  a  pinched  look  and  rapidly  loses  flesh.  Ulcer- 
ation extending  farther  down  the  colon  to  the  rectum  is 
signified  by  more  distinctly  dysenteric  symptoms,  pain  and 
tenderness  over  the  arch  of  the  colon,  more  frequent  mucous 
stools  with  tenesmus;  the  gastric  symptoms,  on  the  other  hand, 
are  less  marked,  and  considerable  appetite,  with  a  fairly  clean 
tongue,  is  often  retained. 

It  is  easy  to  note  down  these  symptoms,  as  they  occur  in 
case  after  case  of  this  dreaded  complication;  but  it  is  much 
more  difficult  to  fix  upon  any  symptom,  if  any,  indeed,  exist, 
that  is  positively  characteristic  of  ulceration.  The  plain  rule 
is,  in  patients  with  tuberculosis,  always  to  treat  intercurrent 
diarrhoea  as  though  it  were  due  to  commencing  ulceration  of 
the  intestines. 

But  in  some  cases  the  diarrhoea  precedes,  or  at  the  time  of 
observation  altogether  masks,  the  lung  symptoms ;  and  it  is 
remarkable  how  completely  even  decided  pulmonary  disease 
may  be  thus  obscured.  The  cough  and  expectoration  may 
cease  or  become  trivial,  and  the  dryness  of  the  pulmonary 
tissue  gives  an  exaggerated  "  vesicularity  "  to  the  respiratory 
murmur  that  masks  existing  defect.  The  recognition  of  this 
fact  is  of  much  importance  in  diagnosis,  the  alternation  in 
prominence  between  the  chest  and  abdominal  symptoms  being 
characteristic  of  intestinal  tubercle. 

It  is  unnecessary  to  dwell  upon  the  later  stages  of  this 
disease :  rapid  wasting  and  exhaustion  from  the  constant  un- 
controllable diarrhoea,  a  depression  of  the  previously  some- 


544  DISEASES   OF  THE  LUNGS   AND   PLEURA 

what   raised   temperature,   aphthous    mouth,   and   lividity   of 
extremities,  are  the  closing  symptoms. 

It  is  a  fact  worthy  of  note  that  even  extensive  ulceration  of 
the  intestines  may  exist  without  any  diarrhoea.  Dr.  Walshe^ 
observed  :  "  Not  only  may  pretty  extensive  ulceration  exist  in 
the  ileum  without  pain,  either  spontaneous  or  elicited  by 
pressure,  but  with  a  confined  state  of  bowels.  Again,  I  have 
known,  in  a  case  running  an  acute  course,  marked  abdominal 
pain  and  tenderness,  conjoined  with  obstinate  constipation, 
where,  after  death,  the  bowels — in  spite,  too,  of  the  frequent 
use  of  purgatives — contained  abundant  solid  faeces,  and  the 
ileum  was  extensively  tuberculised  and  ulcerated." 

In  the  Pathological  Transactions  for  1868,  a  case  of  chronic 
phthisis  with  extensive  and  deep  ulceration  of  the  ileum  is 
recorded  by  one  of  us,^  in  which  constipation  was  a  marked 
symptom  throughout  the  patient's  illness;  and  we  have  met 
with  other  instances.  There  is  no  doubt  that  the  diarrhoea 
is,  to  a  large  extent,  dependent  upon  irritative  catarrhal  in- 
flammation of  the  mucous  membrane  in  the  neighbourhood 
of  the  ulcers,  and  this  is  probably  the  reason  that  it  is  a  more 
prevalent  symptom  in  the  late  summer  and  autumn  months 
than  in  the  winter.  In  some  cases,  however,  the  ulcerations 
are  so  deep  as  extensively  to  destroy  the  muscular  coat,  and 
thus  materially  to  interfere  with  the  peristaltic  movements  of 
the  intestines.  In  others  of  a  more  acute  kind  the  peritoneum 
may  be  much  involved,  and  the  muscular  coat  paralysed.  An 
analogous  state  of  things  in  both  these  respects  sometimes 
obtains  in  typhoid  fever,  in  which  it  is  not  at  all  uncommon 
for  constipation  to  be  present  throughout,  and  we  have 
known  such  cases  to  terminate  fatally  by  perforation. 

These  latter  considerations  bring  home  to  us  the  great  im- 
portance of  a  very  careful  treatment  of  constipation  in  phthisis. 
We  have  seen  perforation  occur  from  the  too  hasty  adminis- 
tration of  a  couple  of  colocynth  and  mercurial  pills  for  con- 
stipation, which  was  present  together  with  ulceration.  The 
stronger  purgatives  should,  therefore,  only  be  administered 
with  great  caution,  and  the  symptom  should,  in  fact,  be  always 
combated  with  the  utmost  gentleness.  For  a  full  considera- 
tion of  the  treatment  of  this  important  complication  we  must 
refer  the  reader  to  a  later  chapter  (p.  694). 


THE   COMPLICATIONS   OF  PULMONARY  TUBERCULOSIS      545 


REFERENCES. 

•  '  (a)  Re-port  on  the  Work  of  the  Pathological  Department  of  the  Bromfton 
Hospital,  April,  1900,  to  April,  1903,  by  P.  Horton-Smith  (Hartley), 
M.D.,  p.  10.     McCorquodale  and  Co.,  Londoiij  1903. 

[b)  Loc.    cit.,   p.    12. 

(^)  Loc.   cit.,  p.    14. 

^  (a)    "Three    Years'    Sanatorium    Experience    of    Laryngeal    Tubercu- 
losis," by  Sir  StClair  Thomson,  M.D.,  F.R.C.P.,  F.R.C.S.,  British 
Medical  Journal,   1914,  vol.  i.,  pp.  801,  818,  and  828.     See  also — 
(3)  "  The  Prognostic  Importance  of  Tuberculosis  of  the  Larynx,"  by 
Sir  StClair  Thomson,  The  Lancet,  1919,  vol.  ii.,  p.  689. 

^  Contribution  to  "  A  Discussion  on  the  Treatment  of  Laryngeal  Tuber- 
culosis," by  W.  Jobson  Home,  M.D.,  British  Medical  Journal,  1905,  vol.  ii., 
p.   1188. 

"  "  The  Channels  of  Infection  in  Tuberculosis,  and  the  Part  played  by 
the  Lymphatic  Glands  in  arresting,  modifying,  or  propagating  the  Infec- 
tion, and  in  preventing  Recurrence  of  the  Disease,  considered  v/ith  Refer- 
ence to  the  Throat,  Nose,  and  Ear,"  by  Jobson  Home,  M.D.,  The  Journal 
of  Laryngology,  Rhinology,  and  Otology.     London,  1907,  vol.  xxii.,  p.  281. 

*  [a)  For  a  discussion  on  the  subject  of  "  Tuberculosis  of  the  Auditory 
Apparatus,"  see  Proceedings  of  the  Royal  Society  of  Medicine, 
Otological  Section^  191S)  vol.  viii.,  p.  15.  See  also — 
(b)  "  The  Clinical  Diagnosis  and  Surgical  Treatment  of  Tuberculosis 
of  the  Temporal  Bone,"  by  W.  Jobson  Home,  M.D.,  M.R.C.P., 
British  Medical  Journal,  1903,  vol.  ii.,  p.  77. 

"  "  Perforation  of  the  Intestine  in  Phthisis,"  by  W.  Saltau  Fenwick, 
M.D.,  and  P.  R.  Dodwell,  M.B.,  The  Lancet,  1892,  vol.  ii.,  p.  133. 

'  A  Practical  Treatise  on  the  Diseases  of  the  Lungs,  by  Walter  Hayle 
Walshe,  M.D.,  4th  edition,  p.  434.     London,  1871. 

'  "  Lung  and  Portion  of  Intestines  from  a  Case  of  Chronic  Phthisis,"  by 
R.  Douglas  Powell,  M.D.,  Transactions  of  the  Pathological  Society  of 
London,  1868,  vol.  xix.,  p.  81. 


35 


CHAPTER  XXXVIII 

ON  HEMOPTYSIS 

HEMOPTYSIS  or  blood-spitting  maybe  defined  as  the  expector- 
ation of  blood  from  or  through  the  lungs  or  bronchial  tubes, 
and  must  be  distinguished  from  false  or  spurious  haemoptysis, 
in  which  the  blood  is  derived  from  the  naso-pharyngeal  or 
buccal  mucous  membrane. 

The  causes  of  haemoptysis  may  be  thus  enumerated : 

1.  HcEfnorrhage  from  the  Pulmonary  Artery  or  its  Capil- 
laries— 

(a)  Rupture  or  wound  of  the  lung  from  external  violence. 

(b)  Active  hypersemia  of  the  lungs,  whether  inflammatory 
or  induced  by  violent  effort  or  excitement.  Such  active  hyper- 
asmia  may  be  primary  as  regards  the  lungs,  or  may  supervene 
or  be  attendant  upon  disease,  such  as  tubercle,  cancer,  hydatid, 
paragonimiasis  (see  p.  76),  etc.,  already  present  in  them.  In 
very  rare  cases  it  may  be  vicarious  in  nature. 

(c)  Mechanical  hypersemia  of  the  lungs,  secondary  to  heart 
disease,  pulmonary  overstrain,  as  in  whooping'-cough,  em- 
bolism of  one  of  the  branches  of  the  pulmonary  artery,  or 
pressure  upon  the  pulmonary  veins  from  tumours,  such  as 
enlarged  glands,  growths  or  aneurism. 

(d)  Changes  in  the  blood,  whether  toxaemic,  purpuric,  scor- 
butic or  otherwise,  resulting  in  capillary  haemorrhages. 

(e)  Necrotic  division  of  vessels  in  the  course  of  softening 
of  consolidations,  such  as  are  met  with  in  phthisis,  syphilis  or 
cancer.  • 

(/)  Aneurismal  dilatation,  or  simple  erosion  of  branches  of 
the  pulmonary  artery  exposed  in  the  course  of  excavation  of 
the  lung,  or  ulceration  of  the  bronchial  mucous  membrane. 

(_g^)  Atheroma  of  the  pulmonary  artery  within  the  lung. 

2.  Hcefnorrhage  from,  the  Bronchial  Artery  or  Capillaries — 
(a)  Capillary  haemorrhage  from  the  bronchial  membrane  of 

546 


ON   HEMOPTYSIS  547 

hypersemic  origin,  or  resulting  from  excessive  blood-pressure, 
hemophilia,  purpura,  scurvy,  or  toxaemic  conditions. 

(b)  Ulceration  or  erosion  of  a  branch  of  a  bronchial  artery. 

3.  Hcemorrhage  from  the  Aorta  or  One  of  its  Great 
Branches. — Aneurism  rupturing  through  the  lung  or  into  a 
bronchus. 

The  above  enumeration  will  suffice  to  remind  the  reader 
that  haemoptysis  is  a  symptom  attendant  upon  many  morbid 
conditions  of  heart,  lung-s,  vessels  and  blood.  For  the  most 
part  this  symptom  is  included  and  sufficiently  discussed  in  the 
descriptions  of  the  diseases  in  which  it  occurs.  In  some  cases 
of  phthisis,  however,  haemoptysis,  from  its  profuseness, 
frequent  recurrence,  and  secondary  consequences,  takes  so 
important  a  part  as  to  merit  separate  consideration.  Taking 
out  of  the  above  Hst  the  causes  of  haemoptysis  operative  in 
phthisis,  they  will  be  found  to  be :  (i)  active  or  inflammatory 
hyperaemia;  (2)  morbid  conditions  of  small  vessels;  (3)  erosion 
or  aneurismal  dilatation  of  larger  vessels. 

Active  or  inflammatory  hyperaemia  is  generally  present  in 
early  phthisis,  and  is  a  prominent  feature  in  the  exacerbations 
of  the  disease.  Haemorrhage  is  by  no  means  necessarily 
attendant  upon  this  condition,  and  does  not  usually  amount 
to  more  than  coloration  or  streaking  of  the  sputum. 

In  the  very  earliest  stage  of  the  disease,  however,  as  it  affects 
successive  portions  of  the  lung,  the  minute  vessels  are 
softened  and  more  or  less  narrowed,  or  even  completely  closed 
by  tuberculous  growth.  From  this  combination  of  softened 
vessel  wall  and  increased  local  blood-pressure  rupture  may 
ensue,  or  it  is  not  impossible  that  it  may  result  from  minute 
aneurismal  dilatation,  after  the  manner  described  by  Charcot 
and  Bouchard  in  cases  of  cerebral  haemorrhage,  but  such  a 
condition  has  not  yet  been  demonstrated  in  the  lung.  The 
very  considerable  haemoptyses  in  the  earlier  periods  of  phthisis, 
and  many  of  the  intercurrent  haemorrhages,  are  attributable  to 
one  or  other  of  these  morbid  conditions  of  the  small  vessels, 
in  conjunction  with,  or  independent  of,  active  hyperaemia. 
Such  a  haemorrhage  may  be  one  of  the  first  symptoms  of 
pulmonary  tuberculosis,  and  it  was  this  fact  which  led  many 
of  the  older  physicians,  from  Hippocrates  downwards,  to 
believe  in  the  reality  of  a  phthisis  ab  hccmoptoe,  in  which  the 


548  DISEASES   OF  THE  LUNGS   AND   PLEURA 

disease  was  thought  to  originate  in  a  bronchial  or  puhnonary 
haemorrhage,  the  inhaled  blood  irritating  the  lung,  and  lead- 
ing subsequently  to  the  morbid  changes  characteristic  of 
tuberculosis. 

As  the  destructive  changes  in  phthisis  advance,  the  larger 
vessels  of  the  affected  portions  of  the  lung  become  softened 
and  then  torn  across,  and  although  as  a  rule  their  lumen  has 
already  been  obliterated  by  previous  thrombosis,  it  occasion- 
ally happens  that  such  is  not  the  case,  and  more  or  less  serious 
hsemorrhage  ensues. 

Aneurism  of  a  branch  of  the  pulmonary  artery  is  a  common 
source  of  fatal,  and  no  doubt  frequently  also  of  non-fatal, 
haemoptysis.  The  first  reported  case  of  pulmonary  aneurism 
was,  we  believe,  that  published  by  Dr.  Fearn^  in  The  Lancet, 
February  6,  1841.  Attention  was  later  attracted  to  the  subject 
by  the  cases  of  Drs.  Cotton^  and  Ouain,^  pubHshed  in  1866. 

These  aneurisms  are  usually  situated  on  a  pulmonary  vessel 
which  has  become  exposed  as  it  crosses  the  wall  of  a  cavity, 
the  aneurism  forming  a  projecting  sac  from  the  vessel  into 
the  cavity.  Loss  of  support  of  the  vessel  on  the  cavity  side, 
and  chronic  inflammatory  changes  in  its  walls,  are  the  causes 
which  lead  to  their  formation.  In  size  they  vary  from  that  of 
a  pea  to  an  unshelled  walnut.  They  may  be  found  at  any 
age,  provided  the  conditions  suitable  for  their  occurrence  are 
present,  but  they  occur  most  frequently  in  chronic  quiescent 
cavities  of  old  date,  where  the  conditions  for  their  production 
are  most  favourable  (Plate  XXXI.).  It  is  to  be  noticed  that 
in  chronic  phthisis  especially  (see  p.  504)  the  general  blood- 
pressure  may  remain  relatively  high,  and  clinical  evidence  is 
in  favour  of  the  probability  of  this  being  more  marked  on 
the  pulmonary  side.*  Aneurisms  are,  however,  sometimes 
met  with  in  association  with  recent  disease  (Plate  XXXIL), 
although  the  vessels  are  more  apt  to  become  occluded  in  such 
acute  processes.  In  a  series  of  2-^  cases  of  fatal  haemoptysis 
occurring  in  phthisis  which  we  have  recorded,^  in  13  the 
aneurisms  occurred  in  cavities  of  some  standing,  with  obvious 
fibrosis  around;  in  the  remaining  10  the  process  was  a  much 
more  recent  one,  the  surrounding  lung  being  the  seat  of  active 
tuberculous  disease. 

It  occasionally  happens  that  a  considerable  aneurism  of  the 
pulmonary  artery  occurs  in  a  lung  in  the  earliest  stage  of 


PLATE   XXXI 


RUPTURED   PULMONARY   ANEURISM    IN   A    CHRONIC 

CAVITY 

The  drawing  shows  a  section  of  the  left  lung.  The  organ  is 
shrunken,  and  the  pleura  over  it  dense  and  greatly  thickened. 
The  upper  lobe  is  seen  to  be  in  a  condition  of  almost  total  excava- 
tion, and  to  communicate  with  a  large  cavity  in  the  lower  lobe, 
on  the  anterior  wall  of  which  an  aneurism  (A),  the  size  of  a  small 
marble,  is  situated.  This  had  ruptured  near  its  upper  portion, 
and  at  the  autopsy  the  lung  was  found  filled  with  recent  blood-clot. 

From  a  man  aged  twenty,  a  shop-assistant,  who  suffered  from 
chronic  pulmonary  tuberculosis  of  two  years'  standing.  During 
the  last  week  of  his  life  he  suffered  on  three  occasions  from 
haemoptysis,  bringing  up  7,  14,  and  5  ounces  respectively.  In 
the  right  lung  a  second  aneurism,  unruptured,  but  of  very 
similar  size  to  the  one  here  depicted,  was  found  (Plate  XXXII.). 

(From  the  Brompton  Hospital  Museum.     §  natural  size.) 


PLATE  XXXI 


'%i^ 


Ruptured  Pulmonary  Aneurism  in  a  Chronic  Cavity. 


To  ftvce  p.  548- 


ON   HEMOPTYSIS  549 

tuberculous  disease,  affording  some  reason  for  the  belief  that 
the  arterial  wall  is  first  affected,  leading  to  the  production  of 
an  aneurism  which  nestles  in  a  pulmonary  recess  or  cavity  of 
its  own  formation.  In  a  case  of  this  kind  recorded  by  the  late 
Dr.  Cayley,*"  which  one  of  us  had  the  opportunity  of  seeing, 
profuse  and  recurrent  haemoptysis  was  for  some  few  weeks 
the  only  evidence  of  pulmonary  disease.  Death  occurred  from 
early  and  acute  disseminated  tubercle. 

Aneurism  of  the  pulmonary  artery  may  present  through  the 
wall  of  a  bronchus,  as  in  a  case  recorded  by  one  of  us  in  the 
Pathological  Society's  Transactions,^  but  we  are  not  aware  of 
any  cases  of  aneurism  of  the  bronchial  arteries  having  been 
reported. 

The  majority  of  cases  of  fatal  haemoptysis  have  been  found 
to  be  due  to  the  rupture  of  a  pulmonary  aneurism  in  a  cavity. 
Ulcerative  erosion  or  rupture  of  large  pulmonary  vessels  with- 
in cavities  accounts  for  the  remainder. 

Bronchial  hsmorrhag-e  to  any  serious  degree  is  now  gener- 
ally regarded  as  of  rare  occurrence.  Slight  haemoptysis  of 
this  type  may  be  observed  in  cases  of  bronchitis,  and  in  the 
plastic  form,  accompanied  by  violent  paroxysms  of  coughing, 
the  loss  of  blood  may  be  considerable.  It  may  occur  also  in 
association  with  the  haemorrhagic  diathesis,  in  purpura,  and  in 
certain  malignant  fevers,  especially  variola.  Sometimes  it  is 
met  with  in  gouty  subjects  and  in  alcoholism,  associated  with 
a  heightened  g'eneral  blood-pressure. 

Syphilitic  or  tuberculous  ulceration  of  the  air-tubes  leads 
frequently  to  slight  haemoptysis,  more  rarely  to  copious 
haemorrhag"e  from  erosion  of  a  larg'e  bronchial  or  pulmonary 
vessel.  A  case  once  came  under  our  notice  in  consultation  in 
which  very  profuse  haemoptysis,  which  had  been  regarded  as 
due  to  the  rupture  of  an  aortic  aneurism,  was  present.  Only 
slight  physical  examination  was  possible  at  the  time,  but  no 
sign  of  aneurism  could  be  found;  the  presence  of  a  greatly 
enlarged  liver  suggested  the  possibiHty  of  syphilis,  and  the 
diagnosis  was  hazarded  of  a  syphilitic  ulceration  of  a  main 
bronchus  causing  the  haemorrhage.  Vigorous  mercurial  in- 
unction and  the  administration  of  iodide  of  potassium  inter- 
nally resulted  in  the  recovery  of  the  patient,  and  the  syphilitic 
view  was  afterwards  fully  confirmed. 

Although  it  is  not  uncommon  for  haemoptysis  to  be  appar- 


550  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

ently  called  forth  by  some  unwonted  effort  or  excitement,  it 
is  by  no  means  so  caused  in  the  majority  of  cases.  Dr.  Wilks 
drew  attention  to  the  frequency  with  which  haemoptysis  occurs 
during  the  night,  and  perhaps  two-thirds  of  the  cases  may  be 
said  to  occur  during  quietude,  and  the  rest,  with  but  rare  ex- 
ceptions, only  during  that  degree  of  physical  effort  or  mental 
excitement  usual  in  ordinary  life. 

Symptoms. — Hemoptysis  is  too  obvious  a  symptom  to  re- 
quire description.  The  blood  expectorated  may  amount  to  no 
more  than  the  slightest  streaking  or  staining  of  the  sputum, 
or  several  pints  may  be  brought  up. 

In  cases  of  decided  haemoptysis  the  patient  is  conscious  of 
a  gurgling  sensation  in  the  bronchial  tubes,  upon  which,  with 
a  succession  of  short  coughs,  the  blood  is  expelled  in  red,  more 
or  less  frothy  sputa.  When  more  profuse,  the  blood  may  pour 
from  the  mouth  in  a  stream,  only  partially  interrupted  by  short 
gasping  coughs.  Such  haemorrhage  may  prove  at  once  fatal 
from  its  very  profuseness,  but  it  is  more  common  in  fatal 
haemoptysis  to  observe  only  a  comparatively  small  amount  of 
blood  actually  expectorated,  the  patient  at  once  succumbing 
to  faintness  and  suffocation  from  the  overwhelming  of  the 
air-passages  with  blood.  These  latter  phenomena  of  sudden 
and  fatal  haemorrhage  scarcely  ever  occur  except  in  tuber- 
culosis of  some  standing,  which  has  resulted  in  pulmonary 
excavation  and  erosion  or  aneurism  within  a  cavity. 

The  blood  in  haemoptysis  is  usually  bright  red,  frothy, 
coagulating  in  the  receiving  vessel  in  flattened  lumps.  When 
very  copious,  it  may  at  the  moment  of  expulsion  be  dark  and 
venous-looking,  but  this  is  exceptional.  After  the  occurrence 
of  an  haemoptysis,  the  sputa  are  blood-stained  for  some  hours, 
or  two  or  three  days,  the  colour  being  at  first  bright  and 
then  becoming  darker.  Sometimes  dark,  grumous-looking 
clots  are  expelled  in  small  quantity  from  the  lung  without  any 
previous  haemoptysis,  a  slight  oozing  having  taken  place,  and 
the  blood  being  retained  for  some  time  before  expectoration. 

In  .cases  of  haemoptysis  the  shock  to  the  system  is  often 
marked,  especially  in  first  attacks.  The  patient  is  agitated 
and  alarmed,  the  features  pallid,  the  expression  anxious,  pulse 
feeble  and  small,  voice  partially  suppressed,  temperature 
lowered  even  to  subnormal.  Reaction  soon  takes  place,  how- 
ever, and,  especially  under  the  often  injudiciously  restorative 


PLATE   XXXII 


PULMONARY  ANEURISM  ASSOCIATED  WITH  RECENT 
TUBERCULOUS  DISEASE 

The  drawing  shov/s  the  upper  portion  of  the  right  lung.  This 
is  the  seat  of  much  scattered  tubercle  of  recent  date  and  in  the 
stage  of  caseation.  In  the  centre  of  the  lobe  is  a  cavity  *he  size 
of  a  small  marble,  completely  filled  by  an  aneurisn.  (A),  which  is 
unruptured,  and  had  given  rise  to  no  signs  during  life.  The 
two  halves  of  the  aneurism  are  shown  in  section. 

From  a  man  aged  twenty,  a  shop-assistant,  who  suffered  from 
chronic  pulmonary  tuberculosis  of  two  years'  duration,  and  who 
died  from  the  rupture  of  a  second  aneurism,  situated  in  a  chronic 
cavity  in  the  left  lung,  which  is  figured  in  Plate  XXXI. 

(From  the  Brompton  Hospital  Museum.     Natural  si^e.) 


PLATE  XXXII 


Pulmonary  Aneurism  associated  with  Recent  Tuberculous  Disease. 


To  face  p.  550. 


ON   HEMOPTYSIS  551 

treatment  of  anxious  friends,  is  ominous  of  fresh  haemorrhage. 
The  pulse  becomes  large,  jerking,  and  more  or  less  dicrotic, 
the  face  flushed,  and  the  conjunctivas  ghstening.  The  sense  of 
weakness  and  prostration  after  early  hsemoptysis  is  often  pro- 
longed, and  bears  no  necessary  relationship  to  the  amount  of 
blood  lost.  The  mental  effect  is  also  sometimes  great;  we 
have  known  even  functional  paraplegia  to  ensue  after  a  slight 
haemoptysis. 

The  temperature,  as  already  remarked,  is  almost  invariably 
depressed  at  the  first  outbreak  of  haemoptysis.  Recovery, 
however,  soon  ensues,  and  the  temperature  returns  to  its 
former  level — febrile  in  those  with  active  disease,  normal  in 
cases  of  quiescent  phthisis.  In  apyrexial  cases  the  tempera- 
ture may  be  sometimes  observed  to  rise  about  the  third  day, 
and  this  may  be  then  attributed  to  secondary  broncho-pneu- 
monia from  inhalation  of  blood  and  septic  matter. 

Diagnosis.  —  The  diagnosis  of  hemoptysis  by  a  skilled 
observer  present  at  the  time  of  its  occurrence  can  never  be 
difficult. 

1.  The  blood  is  distinctly  coughed  up,  is  more  or  less 
aerated,  and  either  pure  or  mixed  with  expectoration. 

2.  After  haemoptysis  there  is  generally  a  staining  of  the 
sputa  for  a  few  hours  or  days. 

3.  Blood  expectorated  from  the  lungs  is  never  watery  and 
non-aerated. 

4.  In  doubtful  cases  inquiries  should  be  made  for  epistaxis, 
and  the  gums  and  pharynx  carefully  examined  (see  Spurious 
Haemoptysis). 

5.  Hasmatemesis  is  frequently  associated  with  a  straining, 
retching  cough;  but  the  history  of  the  case,  the  colour  of  the 
blood,  and  the  absence  of  chest  signs,  are  sufficient  for 
diagnosis.  In  haemoptysis  the  blood  is  usually  alkaline;  in 
haematemesis  it  is  always  acid. 

6.  Only  the  g'entlest  possible  measures  in  the  way  of  physical 
examination  are  justifiable  in  cases  of  haemoptysis.  Percus- 
sion must  be  altogether  avoided.  The  heart-sounds  should  be 
listened  to,  and  the  breath-sounds  over  the  front  of  the  chest 
auscultated,  without,  however,  allowing  any  deep  inspirations 
or  other  efforts  on  the  part  of  the  patient;  by  means  of  a 
flexible  stethoscope  the  bases  of  the  lungs  may  be  sufficiently 
explored  without  disturbing  his  position. 


552  DISEASES   OF   THE   LUNGS   AND   PLEURA 

There  will  usually  be  no  difficulty  in  recognising  at  one  or 
other  apex  more  or  less  crepitant  or  bronchial  gurgling  rales, 
significant  of  the  source  of  bleeding. 

The  pulse  and  temperature  should  be  carefully  noted,  as 
they  furnish  the  needful  indications  for  treatment. 

Prognosis. — In  all  cases  of  early  or  primary  haemoptysis  a 
hopeful  immediate  prognosis  may  be  given,  since  it  is  the 
rarest  possible  occurrence  for  such  attacks  to  prove  fatal.  In 
haemoptysis  occurring  in  a  case  of  quiescent  phthisis  in  which 
there  are  known  to  be  excavations  present,  the  immediate  prog- 
nosis must  be  guarded;  but  however  profuse  the  haemorrhage, 
an  absolutely  fatal  prognosis  is  never  justifiable.  The  fact 
of  the  first  outburst  not  having  proved  immediately  fatal 
always  suggests  the  possibility  of  recovery,  for  it  is  certain 
that  aneurismal  haemoptysis  is  sometimes  completely  re- 
covered from,  the  aneurism  eventually  becoming  firmly  con- 
solidated. 

An  ultimate  prognosis  is  a  much  more  responsible  matter, 
and  should  never  be  given  until  the  patient  has  sufficiently 
rallied  to  allowl  of  a  careful  physical  exploration,  and  a  survey 
of  all  the  facts  of  his  case. 

Excluding  heart  disease,  mechanical  injury,  overstrain  as 
from  whooping-cough,  acute  sthenic  pneumonia,  and  morbid 
blood  conditions,  haemoptysis  in  the  vast  majority  of  instances 
means  the  presence  of  pulmonary  tuberculosis,  and  it  is  one  of 
its  most  important  positive  signs.  Numbers  of  people  doubt- 
less make  a  complete  recovery  after  haemoptysis,  but  such 
recovery  is  only  permanent  in  those  of  good  constitutional 
resistance,  who  can  and  will  accept  the  warning  and  place 
themselves  under  new  and  more  suitable  conditions  of  life; 
Lightly  considered  and  carelessly  treated,  haemoptysis  is  but 
the  precursor  of  grave  destructive  disease. 

Recurrent  Haemoptysis.— The  phenomena  characteristic  of 
recurrent  haemoptysis  are  : 

I.  The  presence  of  a  localised  pulmonary  lesion  presenting 
no  symptoms  of  activity.  2.  Repeated  attacks  of  sudden  and 
severe  outbursts  of  haemorrhage  at  short  intervals,  not 
preceded  by  any  febrile  symptoms,  and  not  necessarily  attended 
or  followed  by  any  extension  of  disease. 

We  may  briefly  allude  to  the  following  case  as  illustrative 
of  this  form  of  haemoptysis  : 


ON   HEMOPTYSIS  553 

In  May,  1867,  there  first  came  under  the  notice  of  Dr.  Douglas 
Powell  at  the  Brompton  Hospital  a  man,  aged  twenty-seven,  described 
as  a  fitter,  who  had  been  ailing  for  some  years  with  occasional  cough. 
He  complained  of  pain  in  the  chest  and  bad  cough,  but,  he  stated, 
without  expectoration ;  he  had  had  streaky  haemoptysis  several  times. 
He  was  doubtful  whether  he  had  lost  weight ;  the  appetite  and  diges- 
tion were  good,  the  bowels  regular,  and  the  pulse  slow.  His  father, 
an  intemperate  man,  had  died  of  consumption  at  the  age  of  forty-four. 
The  patient  himself  had  always  been  a  tolerably  steady  man  of  very 
active  habits.  He  was  of  sanguine  temperament,  clear  complexion, 
medium  height,  and  slight  though  robust  build.  A  striking  feature 
about  him,  and  worthy  of  note,  was  his  extreme  excitability — an  almost 
superfluous  energy  of  character,  which  led  him  to  do  everything  with 
exaggerated  effort. 

At  the  date  of  his  first  attendance  there  was  present  at  the  left  apex 
some  dulness,  with  a  few  clicks. 

On  June  28  he  had  considerable  haemoptysis,  which  was  repeated 
on  August  3,  and  again  on  the  8th,  when  a  pint  of  blood  was  brought 
up,  and  a  note  was  entered  of  the  existence  of  a  small  vomica  at  the 
left  apex.  From  this  date  the  haemorrhage  continued  in  smaller 
quantities  until  the  17th,  when  it  gradually  subsided.  It  was  on  this 
date  that,  having  regard  to  the  continuance  of  the  haemoptysis  and  its 
repeated  occurrence  at  intervals,  together  with  the  absence  of  any 
corresponding  progress  in  the  pulmonary  physical  signs,  which  were 
still  limited  to  the  summit  of  the  left  lung,  the  existence  of  a  small 
aneurism  of  a  pulmonary  vessel  in  this  situation  was  first  suspected. 
He  ceased  attendance  at  the  hospital  at  Christmas  of  the  same  year, 
having  greatly  improved  in  health. 

The  patient  continued  "  well,"  as  he  expressed  it,  and  at  work, 
until  October,  1868,  when  he  returned  to  the  hospital  with  slight  cough, 
and  stating  that  he  had  recently  expectorated  blood,  but  not  so  much 
as  on  previous  occasions. 

At  this  date  there  was  "  dulness  anteriorly  on  the  left  side  to  the 
mamma,  with  high-pitched  bronchial  breath-sound,  pectoriloquy  and 
cavernous  cough;  sounds  dry;  some  crepitus  at  angle  of  left  scapula." 

He  had  another  slight  attack  of  haemoptysis  in  November,  and  at 
Christmas  was  admitted  into  the  hospital,  where  he  remained  a  month, 
during  which  time  he  was  frequently  cautioned  against  displaying  so 
much  energy  in  doing  the  most  trivial  thing,  and  coughing  with  such 
unnecessary  violence.  He  had  no  appreciable  expectoration,  and  left 
the  hospital  feeling  well. 

No  pyrexial  symptoms  had  ever  been  observed  in  this  patient,  and 
during  a  slight  attack  of  haemoptysis,  whilst  in  hospital,  the  tempera- 
ture was  observed  to  be  normal. 

He  was  not  again  seen  until  August,  1870,  when,  having  remained 
quite  well  and  at  work  until  a  few  days  previously,  he  expectorated 
half  an  ounce  of  blood.  The  physical  signs  were  still  limited  to  the 
apex. 


554  DISEASES   OF   THE   LUNGS   AND   PLEURA 

The  patient  ceased  attendance  in  October,  and  continued  pretty  well 
until  March  4,  1871,  when  he  again  attended  with  haemopt3'sis. 
Although  still  spitting  blood  freely,  he,  quite  against  orders,  attended 
personally  from  Battersea  on  March  8,  and  brought  up  a  considerable 
quantity  of  blood  in  the  out-patient  room.  This  attack  proved  the  most 
prolonged  and  desperate  one  he  had  yet  had,  and  nearly  terminated 
fatally.  The  haemorrhage  continued  with  frequent  outbursts  of  half  a 
pint  until  the  30th,  from  which  date  the  attacks  abated  in  violence, 
apparently  rather  from  lack  of  blood-supply  than  from  the  efficacy  of 
remedies,  which,  however,  were  steadily  persisted  in  until  April  13, 
when  there  had  been  no  considerable  hsemoptysis  for  a  week. 

He  again  attended  personally,  though  with  great  difficulty  from  his 
extreme  weakness,  on  May  4.  At  this  date  there  was  noted  at  the  left 
apex  "  retraction  of  lung,  dulness,  cavernous  respiration,  and  rhonchus 
(slight)."  Posteriorly  there  was  "  diffused  crepitation,  with  some 
defective  resonance."  This  was  the  first  occasion  on  which  the  lung 
had  appeared  to  suffer  from  the  effects  of  haemoptysis. 

The  cough  was  troublesome,  especially  in  the  morning ;  and  on  the 
nth  he  was  ordered  ether  and  ammonia  expectorant,  lest  his  violent 
and  unaided  efforts  at  expectorating  should  lead  to  a  fresh  opening  of 
the  probable  aneurism,  which  seemed  to  be  the  only  conceivable  source 
of  such  profuse  and  repeated  haemorrhage.  It  was  extraordinary  to 
note  the  rapidity  with  which  the  patient  regained  flesh,  strength  and 
colour,  although  butcher's  meat  was  only  allowed  every  other  day; 
stimulants  were  cut  off,  and  abundance  of  milk  alone  permitted.  He 
continued  to  take  mineral  acids  and  cod-liver  oil.  He  did  not  at  all 
approve  of  the  diet ;  but  from  previous  experience  of  his  rapid  blood- 
making  qualities,  one  was  convinced  that  a  more  generous  regimen 
would  have  led  to  a  return  of  the  hsemorrhage. 

On  June  8  he  had  one  comparatively  slight  attack  of  haemoptysis, 
and  on  the  29th  the  physical  signs  showed  enlargement  of  the  right 
lung,  the  margin  of  which  reached  across  the  median  line ;  there  was 
still  some  irritative  bronchitis  at  the  left  base,  indicated  by  diffused 
submucous  rales. 

December,  1871. — Beyond  an  occasional  tinge  in  the  morning 
expectoration,  the  patient  had  had  no  more  haemoptysis,  and  had 
returned  almost  to  his  usual  health,  though  the  breath  was  shorter. 
Since  June  he  had  taken  no  oil,  but  for  a  few  weeks  some  digitalis 
was  added  to  his  mixture.  The  restricted  diet  had  been  continued, 
though  less  so  of  late. 

This  man  did  not  attend  the  hospital  ag"ain,  but  was  seen 
about  occasionally,  and  apparently  well,  during-  the  next  five 
years.  The  case  exemplifies  well  the  main  features  of  re- 
current haemoptysis — viz. :  (i)  repeated  copious  hgemorrhage, 
obviously  arising  from  disease  localised  at  one  portion  of  the 
lung;  (2)  pulmonary  disease,  chronic  in  its  course,  and  but 


ON  HAEMOPTYSIS  555 

little  influenced  directly  by  the  haemorrhage ;  (3)  the  hgemop- 
tysis,  though  it  may  prove  directly  fatal,  being  accompanied 
by  no  severe  fever  or  secondary  pneumonia,  and  from  it  the 
patient  frequently  making  a  speedy  recovery. 

The  pathological  condition  common  to  all  these  cases  of 
recurrent  haemoptysis  is  that  of  a  slowly  forming  cavity,  or  one 
formed  by  a  very  localised  process  of  an  active  character,  in 
the  walls  of  which  pulmonary  vessels  still  patent  are  exposed. 
On  such  a  vessel  an  aneurism  then  forms,  projecting  on  the 
cavity  side  of  the  vessel.  It  will  be  observed  that  the  case 
above  described  did  not  begin  with  haemoptysis;  the  man  had 
had  some  dry  coug'h,  and  occasional  streaky  sputum,  for  some 
years  previously;  and  a  few  days  after  the  first  considerable 
haemorrhage  a  vomica  was  found  at  the  left  apex,  where  some 
two  months  previously  there  was  consolidation  and  softening. 

All  cases  of  this  kind  are,  however,  not  necessarily  tuber- 
culous. For  example,  we  have  met  with  an  aneurism  in  a 
bronchial  dilatation,  and  in  another  instance  an  abscess  in  the 
lung  was  attended  with  all  the  features  of  pulmonary  aneur- 
i,smal  haemoptysis,  from  which  the  patient  ultimately  re- 
covered. 

The  danger  in  cases  such  as  these  is  from  the  rapid  outburst 
of  blood,  which  at  once  floods  the  bronchi  and  may  asphyxiate 
the  patient.  In  other  cases  the  actual  amount  of  haemorrhage 
is  the  cause  of  death  on  the  first  occasion.  Nothing  is,  how- 
ever, more  striking  than  the  recovery  of  some  patients  from 
what  appears  to  be  the  most  hopelessly  profuse  haemoptysis. 
Nature  apparently  seizing  the  moment  when,  from  faintness, 
the  blood  is  at  a  standstill,  to  heal  the  breach  by  the  formation 
of  a  coagulum.  Hence  the  importance  in  treating  such  cases 
of  withholding  all  stimulants  till  the  latest  moment.  Rokitan- 
sky  refers  to  another  mode  of  arrest  of  the  haemorrhage  from 
a  large  vessel  in  a  cavity — viz.,  by  the  cavity  becoming  blocked 
by  coagulum,  which  thus  compresses  the  vessel.  We  have 
seen  an  instance,  post-mortem,  in  which  the  apex  of  the  right 
lung-  was  converted  into  a  blood-cyst  as  large  as  a  lemon, 
which  was  quite  closed,  and  which  had  been  produced  by 
haemorrhage  into  a  cavity. 

REFERENCES. 

^  "  Aneurism  of  the  Pulmonary  Artery,"  by  S.  W.  Fearn,  Surgeon, 
F.G.S.,  etc.  (Derby),  Tke  Lancet,  1840-41,  p.  679. 


556  DISEASES   OF  THE  LUNGS  AND   PLEURAE 

^  "  Case  of  Phthisis — Fatal  Haemoptysis  from  the  Rupture  of  a  Small 
Aneurism  of  a  Branch  of  the  Pulmonary  Artery  (under  the  Care  of 
Dr.  Cotton),"  Medical  Times  and  Gazette,  1866,  vol.  i.,  p.  37. 

^  "  Varicose  Aneurysmal  Dilatation  of  Two  Small  Branches  of  the 
Pulmonary  Artery.  Rupture  of  One  of  Them.  Death  by  Sudden  Haemop- 
tysis in  a  Case  of  Phthisis,"  by  Dr.  Quain,  Transactions  of  the  Pathological 
Society  of  London,  1866,  vol.  xvii.,  p.   79. 

*  "  The  Role  of  the  Cardio-vascular  System  in  Pulmonary  Tuberculosis," 
by  Sir  R.  Douglas  PoweU,  Bart.,  K.C.V.O.,  M.D.,  F.R.C.P.,  The  Lancet, 
1912,  vol.  ii.,  p.   1415. 

*  Re-port  on  the  Work  of  the  Pathological  Defartment  of  the  Brom-pton 
Hospital  during  the  Three  Years  April,  1900,  to  April,  1903,  by  P.  Horton- 
Smith  (Hartley),  M.D.,  Table  V.,  p.  22.     London,  1903. 

•^  "  A  Case  of  Haemoptysis  treated  by  the  Induction  of  Pneumothorax 
so  as  to  collapse  the  Lung,"  by  W.  Cayley,  M.D.,  Transactions  of  the 
Clinical  Society  of  London,  1885,  vol.  xviii.,  p.  278. 

''  "  Some  Cases  illustrating  the  Pathology  of  Fatal  Haemoptysis  in 
Advanced  Phthisis,"  by  R.  Douglas  Powell,  M.D.,  Transactions  of  the 
Pathological  Society  of  London,  1870,  vol.  xxii.,  p.  47. 


CHAPTER   XXXIX 

ON   FALSE   OR  SPURIOUS   HEMOPTYSIS 

By  true  haemoptysis  is  meant,  as  we  have  seen,  hsemorrhage 
from  or  throug'h  the  lungs;  either  from  the  lung  texture 
proper,  or  from  the  lining  of  the  bronchial  tubes  ramifying 
through  the  lungs,  or  more  rarely  from  some  external  source, 
the  blood  being  discharged  throug'h  the  lung's. 

By  false  or  spurious  haemoptysis  is  meant  the  spitting  of 
blood  which  has  escaped  from  some  portion  of  the  mucous 
membrane  lining  the  nasal,  buccal,  or  pharyngeal  passages. 
Perhaps  the  true  anatomical  line  of  division  between  true  and 
false  haemoptysis  would  be  at  the  glottis,  for  below  this  point 
the  mucous  membrane  assumes  the  ciliated  columnar  epithe- 
lium characteristic  of  the  bronchial  tract,  whilst  above  the 
epithelium  is  of  the  squamous  kind.  In  true  haemoptysis,  with 
the  exception  of  those  rare  cases  in  which  the  haemorrhage 
comes  from  the  larynx  or  trachea,  or  from  some  external 
source  the  blood  escapes  from  the  pulmonary  or  bronchial 
vessels;  in  false  haemoptysis  from  branches  of  the  carotid 
trunks. 

The  parts  whence  the  blood  of  false  haemoptysis  is  usually 
derived  are  the  nasal  mucous  membrane,  the  pharynx,  the 
gums  and  dental  alveoli.  The  following  are  the  more  im- 
portant conditions  under  which  this  phenomenon  is  met  with. 

I.  In  cases  of  decided  epistaxis  some  of  the  blood  commonly 
trickles  down  the  back  of  the  throat,  and  excites  cough,  by 
which  it  is  removed  in  clots  and  with  staining  of  the  saHva; 
the  source  of  haemorrhage  is  obviously,  however,  the  nasal 
membrane,  and  no  real  difficulty  in  diagnosis  ever  arises.  It 
is  only  in  cases  in  which  the  nasal  haemorrhage  is  but  slight, 
and  attended  with  little  or  no  escape  of  blood  through  the 
anterior  nares,  that  there  is  any  probability  of  the  affection 
being  mistaken  for  haemoptysis.     This  occurrence  may  happen 

557 


558  DISEASES   OF  THE  LUNGS  AND  PLEURA 

at  night,  and  the  patient  wake  up  spitting  blood.  The  absence 
of  fever  and  of  pulmonary  physical  signs,  and  the  detection 
of  blood  mingled  with  the  nasal  mucus  when  expelled,  or  of 
coagula  in  the  nasal  passages,  will  render  the  diagnosis  in 
these  cases  also  clear. 

2.  Ulceration  of  the  throat,  especially  when  malignant,  may 
lead  to  copious  haemorrhage,  and  in  these  cases,  again,  no 
difficulty  is  hkely  to  arise  in  the  way  of  diagnosis. 

3.  A  class  of  cases  is  now  and  again  met  with  which  occa- 
sions much  trouble  to  the  practitioner,  and  requires  decision  in 
management.  These  are  cases  of  feigned  or  hysterical  haemop- 
tysis. Such  are  nothing  more  nor  less  than  downright 
attempts  at  imposition,  the  blood  being  produced  either  by 
sucking  the  gums,  or  by  pricking"  or  incising  them.  The  late 
Sir  George  Johnson^  referred  to  the  case  of  a  young  girl  sent 
up  to  King's  College  Hospital  by  a  lady  interested  in  her,  with 
an  elaborate  history  of  symptoms,  including  blood-spitting. 
The  character  of  the  expectoration,  which  consisted  of  un- 
aerated  saliva  mixed  with  fresh  blood,  was  sufficient  to  indicate 
its  source,  and  on  examining  the  mouth  with  a  bright  Hght, 
about  twenty  fine  cuts  or  scratches  were  discovered  on  the 
mucous  membrane  covering  the  hard  palate.  A  sharp  repri- 
mand and  a  short  course  of  shower-baths  and  steel  tonics 
speedily  removed  the  symptoms. 

In  some  hysterical  cases,  however,  we  have  known  the 
blood-stained  saliva  to  be  liighly  aerated,  probably  produced 
by  sucking  the  gums  after  injuring  them  with  a  needle.  The 
appearance  and  the  physiognomy  of  the  patient  are  generally 
sufficient  to  excite  suspicion,  and  other  hysterical  symptoms 
are  usually  present. 

4.  A  morbid  state  of  the  gums,  a  degree  of  pyorrhoea 
alveolaris,  frequently  arises  from  want  of  due  attention  to  the 
teeth,  or  from  the  presence  of  decayed  stumps  in  the  alveoli. 
On  gently  pressing  the  edge  of  the  gums,  pus  escapes  from 
beside  the  affected  teeth,  and  on  the  slightest  touch  or  friction 
blood  exudes  from  the  mucous  membrane,  which  is  swollen 
and  congested,  a  hvid  line  running  along  the  margin  of  the 
p'um  A  similar  condition  arises  from  the  effects  of  certain 
drugs,  especially  mercury  and,  to  a  much  less  degree,  lead  and 
iodide  of  potassium.  In  these  cases  there  is  fcetor  of  breath, 
and  an  inspection  of  the  gums  and  teeth  at  once  suggests  the 


ON    FALSE   OR   SPURIOUS   H/EMOPTYSIS  559 

probable  source  of  the  blood-spitting,  which  is  usually  insig- 
nificant in  amount,  and  unaccompanied  by  any  cough  or  chest 
symptoms. 

The  treatment  of  these  cases  falls  partly  within  the  province 
of  the  dental  surgeon;  it  consists  in  the  employment  of 
astringent  tooth-powders,  of  which  one  of  the  best  for  the 
purpose  is  composed  of  finely  powdered  kino  one  part,  to  three 
or  five  of  prepared  chalk,  with  or  without  a  little  animal 
charcoal.  Another  preparation  which  we  have  found  of  much 
value  in  cases  of  pyorrhoea  is  a  lotion  composed  of  liquefied 
carbolic  acid,  three  minims;  liquor  potassse,  three  minims;  and 
rosewater  to  the  ounce.  This  should  be  applied  to  the  gums 
on  a  pledget  of  cotton-wool  several  times  a  day.  Any  decayed 
teeth  must  be  removed  or  stopped.  More  or  less  dyspepsia  is 
usually  present  in  these  cases,  partly  arising,  no  doubt,  from 
the  condition  of  the  gums  and  teeth,  and  a  stomach  cough, 
added  to  the  staining  of  the  sputum,  may  suggest  to  the 
patient  that  he  is  consumptive. 

5.  An  insufficient  supply  of  vegetable  food,  a  common 
dietetic  error  among  all  classes  of  people  in  towns,  leads  to  a 
spongy,  congested  state  of  the  mucous  membrane  of  the 
mouth  and  fauces,  of  the  same  kind  as  that  which,  in  a  more 
intense  degree,  is  associated  with  the  other  lesions  character- 
istic of  scurvy.  This  is  one  of  the  common  causes  of  spurious 
haemoptysis.  The  relaxed  condition  of  the  throat,  resulting 
in  the  secretion  of  an  undue  amount  of  viscid  mucus,  gives  rise 
to  cough,  and  the  mucus  expectorated,  or  rather  hawked  up, 
from  the  pharynx,  together  with  the  saHva  from  the  mouth, 
is  from  time  to  time  tinged  with  blood.  It  is  often  difficult 
to  distinguish  this  form  of  false  from  true  haemoptysis.  In- 
deed, the  condition  of  the  mouth  is  but  a  sample  of  that  of  the 
mucous  membranes  generally;  and  the  larger  bronchi,  if 
affected  with  catarrh,  are  apt  to  yield  a  viscid  and  slightly 
stained  secretion.  We  have  observed  in  some  cases  of  phthisis 
a  staining  of  the  expectoration,  which  has  seemed  to  have 
arisen  in  the  samic  way. 

In  the  cases  under  consideration  there  are  no  pulmonary 
signs  to  be  discovered  even  after  a  veiy  careful  examination. 
The  haemorrhage  is  never  in  large  quantity,  and  it  consists  of 
a  tingeing  or  streaking  of  sputum,  which  is  distinctly  made  up 
of  mucus  mixed  with  saliva,  giving  rise  to  a  dirty  red  fluid 


560  DISEASES   OF   THE  LUNGS   AND   PLEURA 

containing  some  little  streaks  or  clots  of  blood.  On  micro- 
scopic examination,  squamous  epithelium  cells  are  seen  in 
abundance,  and  red  blood-corpuscles  are  but  thinly  scattered 
over  the  field.  The  patient  complains  of  the  taste  of  blood 
in  the  mouth,  and  this  is  especially  disagreeable  after  sleep. 
The  nutrition  is  not  good,  the  muscles  are  flabby  and  wanting 
in  tone,  and  the  patient  feels  languid  and  out  of  sorts.  There 
is  commonly  some  ansemia  present. 

A  most  favourable  prognosis  may  confidently  be  given  in 
these  cases,  if  we  are  quite  satisfied  as  to  the  absence  of  any 
pulmonary  sign. 

In  treatment  the  diet  must  be  attended  to,  an  abundance  of 
fresh  fruit  and  vegetables  being  added.  Five  or  ten  grains  of 
citrate  of  iron  should  be  ordered  in  fresh  lemon-juice  two  or 
three  times  a  day,  and  cod-liver  oil  may  often  be  given  with 
g'reat  advantage.  Some  tannin  solution  should  be  used  as  a 
garg'le,  and  to  rinse  the  mouth.  A  pleasant  mouth-wash  and 
gargle  to  use  night  and  morning  consists  of  Hazeline  gii., 
Glycerini  Boracis  sii.,  Eau-de-Cologne  §1.,  Aquam  Rosas 
ad  §viii. ;  one  tablespoonful  to  a  wineglass  of  water  to  rinse 
the  mouth,  and  some  undiluted  lotion  dropped  on  to  a  soft 
badger's-hair  toothbrush  previously  dipped  in  water,  to  brush 
the  gums. 

In  cases  of  phthisis  in  which  we  suspect  this  morbid  condi- 
tion of  the  bronchial  mucous  membrane  to  be  present,  fresh 
lemon-juice,  a  not  unpleasant  vehicle  for  cod-liver  oil,  is 
valuable. 

6.  In  certain  cases  of  ansemia,  attended  with  all  the  other 
phenomena  of  that  disease,  the  mucous  membrane  of  the 
mouth  and  fauces,  although  pallid  in  appearance,  exudes  a 
sanguineous  fluid,  which,  mixed  with  the  saliva,  causes 
spurious  hcemoptysis.  There  is  in  these  cases,  so  far  as  one 
can  discover,  no  definite  bleeding-point  to  be  seen,  but  in  the 
course  of  twenty-four  hours  a  considerable  amount  of  blood 
will  transude  through  the  vessels.  The  transudation  is 
ordinarily  very  slow,  and  in  the  daytime  is  scarcely  noticed; 
but  during  the  night  some  accumulation  takes  place,  and,  on 
waking,  the  patient  expels  perhaps  an  ounce  or  more  of  bright 
red  unaerated  fluid,  containing  a  few  coagulated  films,  giving 
an  appearance  closely  resembling  that  of  currant  jelly  and 
water.    Some  of  the  sanguineous  fluid  often  escapes  from  the 


ON  FALSE  OR  SPURIOUS   HEMOPTYSIS  56 1 

mouth  upon  the  pillow  during  sleep.  The  patients  suffering 
from  this  affection  are  mostly  females.  Amongst  other 
symptoms  of  anaemia  the  menstruation  is  disordered  or 
suppressed,  and  commonly,  but  not  always,  at  the  menstrual 
period  the  escape  of  blood  from  the  mouth  is  considerably 
increased.  Probably  from  the  same  cause — an  increased 
blood-pressure  finding-  relief  at  the  surface  of  least  resistance 
— any  extra  exertion  is  apt  to  produce  an  increase  in  the 
sanguineous  flow.  The  real  pathology  of  these  cases  is,  how- 
ever, confessedly  obscure;  but  this  is  the  variety  of  false 
haemoptysis  for  which  we  are  most  often  consulted.  The 
patients  are  short  of  breath ;  they  sometimes  have  a  hard  cough, 
and  complain  of  pain  in  the  left  side  and  considerable  prostra- 
tion, which  symptoms,  with  increasing  pallor  and  blood- 
stained expectoration,  are  quite  sufficient  to  persuade  them 
and  their  friends  that  they  are  consumptive. 

In  such  cases  the  greatest  pains  must  be  taken  to  exclude 
the  presence  of  tuberculosis.  The  sputum,  however  scanty, 
must  on  several  occasions  be  carefully  examined  for  tubercle 
bacilli,  if  necessary,  using  concentration  methods  (p.  574),  and 
a  watch  kept  upon  the  patient's  weight  and  temperature.  As 
regards  physical  diagnosis,  the  respiratory  sounds  will  usually 
be  found  to  be  weak  and  partly  suppressed  from  want  of 
muscular  power.  The  percussion  is,  however,  even  on  the 
two  sides,  and  the  respiration,  although  feeble,  is  vesicular. 
The  character  of  the  cough,  both  as  heard  through  the  stetho- 
scope and  otherwise,  is  usually  quite  distinct  from  that  of  chest 
disease.  Moreover,  all  the  signs  of  anaemia  are  present, 
venous  hum,  arterial  murmurs,  and  so  forth,  and  the  "pain  in 
the  chest "  is,  without  much  difficulty,  ascertained  to  be  either 
inframammary  neuralgia  or  gastrodynia.  Some  patients  with 
this  form!  of  spurious  haemoptysis  have  plenty  of  colour  in  the 
cheeks,  and  are  plump  rather  than  emaciated ;  but  they  never- 
theless present  other  evidences  of  anaemia.  The  careful 
observation  of  a  large  number  of  these  cases  for  long  periods 
enables  us  to  say  that  it  is  very  unusual  for  them  to  develope 
phthisis. 

The  condition  calling  for  treatment  is  the  anaemia.  More 
fresh  meat  must  be  taken,  and,  if  necessary,  some  hydrochloric 
acid  and  pepsin  added  to  aid  digestion.  In  some  cases  there 
is  considerable  disorder  of  stomach  present,  which  must  be 

36 


562  DISEASES   OF  THE  LUNGS   AND   PLEURA 

first  set  right  before  the  remedies  appropriate  to  angemia  can 
be  given.  These  remedies  are  the  astringent  forms  of  iron. 
Cold  salt  baths  or  sea-bathing  allowed  only  for  a  very  brief 
time — one  or  two  minutes — and  immediately  followed  by 
vigorous  friction,  are  most  useful  in  the  convalescent  stage. 
Abundance  of  fresh  air  and  out-of-door  exercise  is,  of  course, 
to  be  insisted  upon.  The  patients  and  their  friends  are  often 
much  afraid  of  fresh  air,  and  the  cases  have  usually  at  the 
period  at  which  they  come  under  observation  been  aggravated 
by  confinement  in  warm  and  ill-ventilated  rooms.  If,  as  often 
happens,  there  are  decayed  teeth  present,  setting  up  irritation 
in  the  gums,  and  increasing  the  disposition  to  haemorrhage, 
these  should  be  attended  to.  Some  calcium  lactate  may  be 
given  with  syrupus  calcii  lacto-phosphatis,  and  a  little  reduced 
iron  with  the  meals. 

7.  General  haemorrhage  from  the  whole  mucous  membrane 
of  the  mouth  is  sometimes  seen  in  haemophilia.  As  in  the 
variety  described  under  the  preceding  heading,  no  per- 
ceptible lesion  is  discoverable  in  the  mucous  membrane,  but 
the  haemorrhage  in  this  case  is  usually  so  considerable '  in 
amount  as  to  prevent  any  possibility  of  mistaking  its  nature, 
and  other  signs  of  the  disease  may  be  present. 

Such  are  the  more  important  conditions  under  which 
spurious  haemoptysis  is  met  with.  In  all  cases,  however,  in 
which  the  cause  is  not  apparent,  a  very  careful  examination 
of  the  pharynx,  back  of  the  tongue,  and  of  the  laryngeal 
region  should  be  made  with  the  laryngoscope.  In  this  way 
it  has  happened  that  a  small  area  of  ulceration  has  been  found, 
for  example,  on  the  posterior  aspect  of  the  tongue,  on  treat- 
ment of  which  the  blood-spitting  has  ceased. 

REFERENCE. 

^  "  Clinical  Remarks  on  Three  Cases  of  Malingering,  namely,  Two 
Cases  of  Pretended  Blood-Spitting  or  Vomiting,  and  One  of  Suppression 
of  Urine,"  by  George  Johnson,  M.D.,  Medical  Times  and  Gazette,  1862, 
vol.  i.,  p.  428. 


CHAPTER  XL 

ON     OTHER    IMPORTANT    COMPLICATIONS    OF    PULMONARY 

TUBERCULOSIS 

Tuberculous  Meningitis. — This  fatal  complication  of  pul- 
monary tuberculosis  occurs  as  part  of  a  secondary  and  general- 
ised miliary  infection.  When  the  meninges  of  the  brain  are 
involved  in  this  outbreak  of  tubercle,  the  special  symptoms 
that  arise  are  so  grave  as  to  set  aside  from  view  all  other 
conditions  present. 

A  notable  feature  about  tuberculous  meningitis,  when  it 
complicates  phthisis,  is  the  uncertainty  and  insidiousness  of 
its  supervention.  It  is  happily  a  somewhat  rare  complication 
— occurring-  in  only  7  of  our  275  autopsies^" — yet  there  is  no 
case  of  phthisis,  and  no  stage  of  any  case  in  which  the  condi- 
tions for  its  possible  occurrence  are  not  present  Thus  a  child 
may  have  a  small  apex  lesion,  which  has  resulted  in  some  local 
induration  and  flattening,  with  complete  subsidence  of  all 
•symptoms;  she  has  steadily  improved,  and  is  regarded  by  her 
parents  as  well,  although  the  doctor  pronounces  her  chest  still 
to  be  delicate,  when  suddenly  she  developes  brain  symptoms, 
which  terminate  fatally  within  three  weeks.  Such  is  a  common 
history. 

We  will  briefly  relate  one  or  two  cases  which  may  be  re- 
garded as  typical  of  their  kind. 

Case  i. — George  B.,  aged  twelve,  a  thin,  pale,  neglected-looking 
boy,  was  admitted  into  hospital  on  August  26  with  a  history  of  recent 
bronchitis  and  presenting  the  remains  of  a  broncho-pneumonia,  with 
some  hectic  symptoms.  On  September  18  vomiting  commenced, 
occurring  after  food,  and  attended  with  some  diarrhoea,  a  coated 
tongue,  and  a  slight  rise  of  temperature  (99°).  The  vomiting  became 
more  frequent,  and  persisted  through  the  next  seven  or  eight  days. 
The  face  was  flushed,  the  skin  hot  and  perspiring.  No  headache  was 
complained  of.     On  the  third  day  of  these  symptoms  the  urine  yielded, 

563 


564  DISEASES   OF  THE  LUNGS  AND   PLEURA 

on  boiling  a  heavy  cloud  of  phosphates,  a  sign  which  we  have  observed 
in  other  cases  of  the  disease.  On  the  tenth  day  (September  27)  the 
patient  became  unconscious,  and  the  following  note  was  made  : 
"  Pulse  76,  irregular,  lips  dry,  tongue  furred.  Expression  of  face 
drowsy,  suspicious.  Will  not  answer  questions.  Tries  to  put  out 
tongue  when  sharply  told  to  do  so,  but  fails.  Is  slightly  delirious. 
Respirations  20  in  the  minute,  temperature  ioo-8°.  There  is  slight 
occasional  twitching  of  the  left  arm  and  pectoral  muscle.  When 
aroused  drinks  oatmeal-water  with  avidity.  Evidently  tries  to  answer 
questions  put  to  him  but  fails  to  do  so.  At  9  p.m.  twitching  of  both 
arms  and  legs  observed,  with  picking  at  bedclothes,  and  grasping  at 
nothing.  Has  not  vomited  after  taking  cream  and  brandy ;  pulse  80 ; 
temperature  100°. " 

On  the  eleventh  day,  September  28,  temperature  100-2°,  pulse  80, 
the  patient  more  restless.  Fingers  continually  working,  scratching, 
or  pulling  at  teeth.  Muscles  of  neck  and  back  rigid.  At  4  p.m.  : 
movements  of  arms  and  legs  more  violent.  Rigidity  of  back  more 
marked;  temperature  102-2°;  bowels  open  from  medicine;  motions 
loose.  September  29  :  temperature  101-2°,  pulse  80,  weaker.  Slight 
external  strabismus  of  left  eye.  September  30  :  10  a.m.,  temperature 
102-4;  7  p.m.,  103°,  pulse  120.  Eyes  roll  slowly  from  side  to  side, 
pupils  dilated.  October  i  and  2  :  morning  temperature  ioi-6°. 
Emaciation  increasing.  Some  resistance  to  extension  of  arms.  Con- 
junctivae more  sensitive,  pulse  130,  regular.  Patient  lingered  for  a 
week  longer  in  much  the  same  state,  and  then  sank  on  the  twenty-first 
day.  The  post-mortem  revealed  the  usual  evidence  of  meningeal 
tuberculosis. 

In  this  case  the  insidiousness  of  onset  v^^as  well  illustrated. 
During-  the  first  days  of  the  attack  no  headache  was  com- 
plained of,  nor  did  the  boy  at  any  time  suffer  much  from  this 
symptom.  Obstinate  vomiting  resisting  all  treatment  was  up 
to  the  time  of  unconsciousness  the  only  definite  symptom,  and 
its  significance  was  at  first  obscured  by  other  evidences  in 
tongue  and  bowels  pointing  to  gastric  derangement.  Later, 
twitchings  and  irregular  movement  of  the  limbs,  with  increas- 
ing unconsciousness,  rigidity  of  neck,  strabismus,  and  blind- 
ness were  present  in  this,  as  in  most  other  cases  of  meningitis. 

Case  2. — In  this  case,  that  of  an  adult,  aged  thirty-three,  with 
advanced  phthisis,  the  first  symptoms  were  headache  and  confusion  of 
vision,  which  latter  was  ascribed  to  yoo  grain  hyoscyamine  given  in  a 
cough  linctus.  The  pupils,  however,  were  not  dilated.  The  patient 
vomited  twice  in  the  course  of  the  next  two  days,  and  on  the  fifth  day 
twitchings  of  the  flexor  tendons  were  observed.  Two  days  later  the 
pupils  became  unevenly  contracted.  The  patient  became  drowsy ;  he 
could  not  find  words  to  answer  questions.     He  died  on  the  nineteenth 


ON  COMPLICATIONS   OF  PULMONARY  TUBERCULOSIS      565 

day  after  the  commencement  of  symptoms,  irregularity  of  pulse  and 
breathing,  drowsiness,  and  variable  twitching  of  the  limbs,  being 
observed  towards  the  end. 

The  following  propositions  embrace  what  is  reliable  in  the 
diagnosis  of  this  complication,  sometimes  so  startling,  at 
others  so  insidious,  in  its  onset. 

1.  Persistent  headache  and  vomiting  are  the  most  common 
first  sy}nptoms  of  the  disease.  They  may  or  may  not  he  com- 
bined. They  are  usually  associated  with  furred  tongue  and 
disordered  bowels,  which  tend  to  mask  their  significance. 

The  headache  of  tuberculous  meningitis  does  not  affect  with 
constancy  any  particular  portion  of  the  head.  It  is  sometimes 
frontal,  often  over  the  crown  of  the  head,  occasionally  at  the 
back  or  on  one  side.  Although  always  a  sign  to  cause  anxiety 
when  it  occurs  at  all  severely  or  persistently  in  phthisis,  yet  it 
is  never,  even  when  associated  with  vomiting,  sufficient  to 
enable  us  to  form  a  diagnosis.  In  several  cases  we  have  found 
headache  so  severe,  persistent,  and,  taken  together  with  the 
general  aspect  of  the  patient,  so  apparently  characteristic  of 
meningitis,  as  to  have  led  us  to  feel  very  apprehensive  as  to 
its  real  significance;  yet  again  and  again  our  suspicions  have 
proved  to  be  unfounded.  On  the  other  hand,  in  the  majority 
of  cases  of  true  tuberculous  meningitis  that  have  come  under 
our  observation,  other  suspicious  symptoms  have  been  asso- 
ciated with  the  headache  until  the  appearance  of  more  decided 
signs  removed  all  doubt.  Hence  headache  or  vomiting, 
although  not  sufficient  for  diagnosis,  are  signs  which,  if  not 
readily  relieved  by  treatment,  should  always  arouse  grave 
suspicions. 

2.  Disordered  vision,  impaired  memory,  and  confusion  of 
ideas  are  signs  which,  taken  in  association  with  headache,  are 
almost  diagnostic;  the  supervention  of  muscular  twitchings 
or  convulsions  is  of  the  highest  significance. 

Any  or  all  of  these  signs  may  closely  follow  the  appearance 
of  headache  or  vomiting.  They  may,  one  or  more  of  them, 
constitute  the  first  symptoms  of  the  disease.  Paralysis  of  the 
third  or  sixth  nerve  usually  occurs  among  the  later  symptoms, 
when  the  effused  lymph  and  contractile  tissue  drags  and  exer- 
cises pressure  upon  the  nerves.  Ophthalmoscopic  examina- 
tion of  the  fundus  may  yield  a  valuable  positive  result,  but  the 
absence  of  tubercles  in  the  choroid  signifies  little,  as  they  are 


566  DISEASES   OF  THE  LUNGS   AND  PLEURA 

present  in  only  a  minority  of  cases.  Thus,  choroidal  tubercles 
were  found  in  only  fourteen  out  of  forty-seven  consecutive 
cases  (29-8  per  cent.)  examined  post-mortem  at  St.  Bartholo- 
mew's Hospital,  and  during,  life  they  are  discovered  even  less 
frequently." 

3.  Drowsiness  deepening  into  coma,  hut  often  with  intervals 
of  consciousness,  is  the  most  constant  of  the  later  symptoms 
of  tuberculous  meningitis.  It  depends  upon  effusion  into  the 
ventricles. 

4.  Irregular  pulse  and  irregular  respiration  are  amongst  the 
occasional  early  signs  of  tuberculous  meningitis. 

Both  irregularity  of  the  pulse  and  of  the  respiration  are  not 
uncommon  after  the  period  of  coma,  but  they  are  then  signs 
of  little  importance.  A  marked  irreg'ularity  of  the  pulse 
occurring,  however,  early  in  the  attack  is  of  greater  signifi- 
cance than  is  usually  recognised.  The  pulse  is  commonly 
rather  slow  than  quick,  sometimes  markedly  infrequent.  The 
respirations  are  rarely  affected  during  the  early  stages  of  the 
disease. 

5.  The  temperature  is  as  a  rule  not  much  elevated.  It  is 
more  often  raised  towards  the  end  of  the  attack,  its  rise  being 
apparently  associated  with  secondary  inflammatory  lesions. 
It  is  of  little  or  no  value  in  diagnosis. 

6.  Kernig's  Sign. — A  common  symptom  met  with  in  menin- 
gitis is  that  known  as  Kernig's  sign.  By  this  is  meant  the 
inability  to  straighten  the  patient's  leg  when  the  thigh  is  placed 
at  a  right  angle  to  the  trunk,  owing  to  contraction  induced 
in  the  calf  muscles.  The  sign  is  not,  however,  limited  to 
meningitis,  and  its  diagnostic  value  is  correspondingly 
diminished. 

7.  Lumbar  Pimcture.— In  cases  of  doubt  the  diagnosis  is 
much  aided  by  a  lumbar  puncture.  If  tuberculous  meningitis 
be  present,  the  fluid  withdrawn  will  be  found  to  be  clear  or 
faintly  turbid.  The  albumin-content  is  increased,  so  that  no 
long'er  a  "  faint  haze  "  is  observed,  but  a  definite  ring  at  the 
line  of  junction  when  the  cold  nitric  acid  test  is  applied,  and 
on  boiling  with  an  equal  quantity  of  Fehling's  solution  no 
reduction  is  now  obtained.  If  a  film  from  the  deposit  ob- 
tained by  centrifugalisation  be  stained,  lymphocytes  will  be 
usually  found  to  form  the  great  majority  of  the  cells  present. 
When  cultivated  on  ordinary  media  the  fluid  is  sterile,  but 


ON   COMPLICATIONS   OF   PULMONARY   TUBERCULOSIS      567 

tubercle  bacilli  may  often  be  demonstrated  if  the  small 
fibrinous  clot,  which  in  many  cases  forms  on  standing,  be 
teased  out  on  a  slide  and  stained  by  the  Ziehl-Neelsen  method, 
as  recommended  by  Dr.  Graham  Forbes.^ 

In  these  respects  tuberculous  meningitis  differs  from  other 
varieties  of  acute  meningitis.  In  the  latter  the  fluid  will  be 
found  more  turbid,  owing  to  the  greater  number  of  cells 
present,  and  the  differential  count  shows  that  polymorphonu- 
clear leucocytes  predominate.  On  staining  films  various 
organisms,  whether  meningococci,  pneumococci,  streptococci 
or  others,  will  be  observed,  and  their  presence  will,  as  a  rule, 
be  confirmed  by  cultivation.  In  health  the  cerebro-spinal  fluid 
is  clear,  and  almost  free  from  cells. 

8.  The  blood-count  shows,  as  a  rule,  a  leucocytosis,  the  in- 
crease in  number  of  the  white  cells,  which  may  early  in  the 
course  of  the  disease  number  12,000,  being  chiefly  due  to  the 
presence  of  polymorphonuclear  cells. 

The  duration  of  this  disease  is  varied;  it  may  terminate  in 
a  few  hours,  or  days,  or  weeks,  and  is  generally  fatal  before 
the  twenty-first  day.  Patients  will  sometimes  linger  for  many 
days  in  a  state  of  complete  insensibility  from  effusion  into 
the  ventricles.  It  is  not  infrequent  for  a  deceptive  amend- 
ment of  symptoms  of  short  duration  to  take  place  before  the 
fatal  issue. 

Lardaceous  Disease. — In  about  lo  per  cent,  of  cases  of 
phthisis  lardaceous  changes  are  found  at  the  autopsy  in  certain 
organs.  The  table  on  p.  568  shows,  in  detail,  the  results 
obtained  in  263  cases  of  chronic  pulmonary  tuberculosis  upon 
which  autopsies  were  performed  by  one  of  us  at  the  Brompton 
Hospital  during  the  years  1900  to  1903.^*  In  these  statistics, 
it  should  be  added,  we  are  alluding  to  the  coarse  degrees  of 
lardaceous  degeneration  demonstrated  to  the  naked  eye  by 
the  iodine  test;  in  a  considerably  larg-er  percentage  micro- 
scopic examination  would  have  revealed  a  trace  of  the 
condition. 

The  figures  given  below  closely  agree  with  those  quoted  by 
Sir  J.  King'ston  Fowler"  from  records  taken  at  the  same  hos- 
pital during  the  years  1893-94.  It  would  seem,  however,  that 
formerly  lardaceous  disease  was  more  often  met  with.  Thus, 
in  ninety-nine  post-mortem  examinations,  made  consecutively 
at  the  Brompton  Hospital  by  one  of  us  in  the  years  1869  to 


568 


DISEASES   OF   THE  LUNGS   AND   PLEURA 


1875,  it  was  found  in  twenty  cases,  eight  male  and  twelve 
female,  or  in  about  20  per  cent,  of  the  whole,  a  difference  in 
percentage  from  that  in  the  table  below,  which  is  possibly  to 
be  attributed  to  the  more  hygienic  conditions  under  which  the 
disease  is  now  treated,  and  the  diminished  liability,  therefore, 
of  the  patients  to  be  infected  with  virulent  secondary  organ- 
isms. In  the  twenty  patients  just  referred  to  the  pulmonary 
disease  had  a  maximum  duration  of  sixty-six  months,  a 
minimum  of  four  months,  with  a  mean  of  twenty-six  months. 
The  spleen  was  affected  in  nineteen  of  the  twenty  cases. 

Table  showing  the  Frequency  of  Occurrence  of  Laedaceous  Disease 
IN  Chronic  Pulmonary  Tuberculosis,  and  the  Organs  chiefly 
affected,  based  upon  263  Consecutive  Autopsies  (188  Males,  75 
Females). 


Males. 

1     Males 
per  Cent. 

Females. 

Females 
per  Cent. 

Total. 

Total 
per  Cent. 

Present  in             

18 

i 

1      9"5 

10 

13  3 

28 

10 -6 

Analysis  of  above — 

Spleen  affected 

14 

7'4 

8 

10-6 

22 

8-3 

Kidneys      „ 

II 

j      5-8 

7 

93 

18 

6-8 

Liver 

II 

'      5-8 

6 

8-0 

17 

6*4 

Intestines  ,, 

7 

;   37 

6 

8-0 

13 

4'9 

Stomach     ,, 

4 

21 

3 

4-0 

7 

2-6 

From  the  figures  above  quoted  it  will  be  seen  that  in  lar- 
daceous  disease  following  tuberculosis  of  the  lungs  the  spleen 
is  the  organ  most  commonly  affected,  and  after  this  the  kidney 
and  liver  in  about  equal  proportions.  Less  frequently  the 
intestines,  stomach,  and  suprarenals,  and  occasionally  other 
organs — such  as  the  lymphatic  glands,  the  thyroid,  testes,  etc. 
— show  the  characteristic  change.  This  especial  vulnerability 
of  the  spleen  is,  perhaps,  peculiar  to  cases  originating-  in 
phthisis;  for  we  may  remark  that  in  118  cases  collected  at 
St.  George's  Hospital  by  the  late  Dr.  Dickinson,^,  of  which 
forty-three  at  most  originated  in  phthisis  (suppuration  of 
various  kinds  and  syphilis  accounting  for  the  remainder),  the 
order  of  frequency  was  as  follows  :  kidneys  affected  in  95 
cases;  spleen  in  76;  liver  in  65;  intestines  in  35;  stomach  in  9. 

The  lardaceous  change  in  phthisis  is  no  doubt  connected 
with  the  suppuration  which  is  taking  place  in  the  lungs  and 
the  imperfect  drainage  and  consequent  absorption  of  toxines, 
which  is  inseparable  from  this  condition.     In  this  connection 


ON  COMPLICATIONS   OF  PULMONARY  TUBERCULOSIS      569 

it  is  interesting  to  recall  that  the  change  has  been  produced 
experimentally  in  animals  by  Krawkow,  Alan  Green/  and 
others,  as  the  result  of  the  inoculation  of  attenuated  cultures 
of  pyogenic  org^anisms  or  their  toxines. 

Lardaceous  disease  may  be  recog'nised  as  a  complication  in 
phthisis  by  the  detection  of  an  enlarged  spleen,  which  presents 
below  the  cartilages,  firm  and  smooth  on  palpation.  The  liver 
also  may  be  found  large,  smooth,  and  hard,  with  well-defined 
and  rigid  marginal  outline.  In  many  cases  albuminuria  is  the 
first  sign,  considerable  in  amount,  and  accompanied  by  hyaline 
casts  and  a  variable  degree  of  dropsy. 

It  only  rarely  happens,  and  chiefly  in  the  fibroid  variety  of 
phthisis,  that  the  lardaceous  disease  causes  death,  and  in  these 
cases  the  fatal  result  is  due  to  kidney  complication.  In  a  few 
instances  the  intestinal  mucous  membrane  is  gravely  involved, 
and  obstinate  diarrhoea  exhausts  the  patient.  The  appearance 
of  the  change  is  often  associated  with  chronicity. 

Albuminuria. — The  presence  of  albuminuria  is  rare  in  the 
early  stages  of  phthisis.  Later  on  it  may  result  from  simple 
chronic  nephritis  or  lardaceous  degeneration,  both,  however, 
less  common  now  than  formerly,  or  tuberculous  disease  of  the 
kidney  and  pelvis  (or  other  portion  of  the  urinary  tract),  the 
so-called  scrofulous  disease  of  the  kidneys  described  by  earlier 
writers. 

(a)  Lardaceous  degeneration  of  the  kidneys  is  not  common 
in  phthisis,  and  is  somewhat  less  frequently  observed  than  a 
similar  affection  of  the  spleen.  It  occurs  in  the  more  chronic 
cases,  and  is  often  associated  with  a  like  affection  of  other 
organs. 

A  considerable  degree  of  renal  dropsy  may  attend  the 
albuminuria  arising  from  this  cause,  and  the  abdomen  is 
generally  enlarged  from  the  presence  of  an  amyloid  or  amylo- 
fatty  liver.  Diarrhoea  is  often  a  marked  symptom  in  this  form 
of  phthisical  albuminuria,  and  sometimes  uraemic  vomiting 
and  convulsions  occur,  but  much  less  frequently  than  in  other 
forms  of  nephritis. 

(b)  Another  cause  of  albuminuria  and  renal  phenomena 
in  tuberculosis  is  a  form  of  nephritis,  parenchymatous 
in  nature,  in  which  the  kidney  is  somewhat  enlarged,  its 
capsule  adherent,  the  organ  softer  than  natural,  and  less  dry 
on  section,  presenting  a  swollen  cortex  of  a  mottled  appear- 


570  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

ance  from  points  and  streaks  of  fatty  deg"eneration.  This 
kidney  does  not  give  the  amyloid  reaction.  The  albuminuria 
is  considerable  in  amount,  and  there  is  a  tolerably  copious 
sediment  from  the  urine,  containing  abundant  epithelial  and 
fatty  casts. 

This  form  of  renal  complication  is  perhaps  of  less  frequent 
occurrence  than  formerly.  It  is  much  more  serious  than  the 
lardaceous  form,  being  attended  with  scantiness  or  suppres- 
sion of  urine,  obstinate  and  exhausting  vomiting  or  diarrhoea, 
or  pulmonary  oedema  and  asthmatic  phenomena,  and  other 
g'rave  ursemic  symptoms. 

(c)  The  kidneys  necessarily  partake  in  the  pathology  of 
acute  miliary  tuberculosis,  and  in  patients  dying  of  chronic 
phthisis  the  occurrence  of  a  few  miliary  tubercles  in  the 
kidneys  is  by  no  means  uncommon.  In  our  own  autopsies 
we  found  such  tubercles,  visible  to  the  naked  eye,  in  28  out  of 
263  cases  of  chronic  pulmonary  tuberculosis,  a  percentage  of 
io"6;  whilst  Dr.  Joseph  Walsh,^"  examining  60  cases,  was  able 
to  demonstrate  their  presence  microscopically  in  35  (58  per 
cent.).  In  conformity  with  these  results,  we  may  add  that 
Drs.  Ravenel,  Walsh,  and  Smith^*  have  proved  that  in  advanced 
phthisis  tubercle  bacilli  not  infrequently  pass  into  the  urine, 
and  by  inoculating  guinea-pigs  with  the  washed  sediment  of 
two  litres,  they  were  able  to  demonstrate  their  presence  in 
14  out  of  17  cases.  Bacilli  may  thus  find  a  nidus  in  the  kidney, 
and  give  rise  to  a  few  miliary  tubercles.  Ulcerative  tubercu- 
losis of  the  organ,  however,  with  its  attendant  caseating 
masses  and  vomicae,  is  rare  as  a  complication  of  phthisis.  Out 
of  263  autopsies,  we  only  found  such  a  complication  in  6.  Its 
occurrence  is  indicated  by  lumbar  pain,  increased  frequency 
of  micturition,  and  especially  by  the  presence  of  a  thick  deposit 
of  pus  in  the  urine,  in  which  tubercle  bacilli  will  be  found. 
Like  some  other  tuberculous  manifestations,  it  is  more 
common  as  a  primary  local  affection,  upon  which  pulmonary 
disease  may  later  be  engrafted. 

The  occurrence  in  the  urine  of  the  ordinary  diazo-reaction 
or  of  the  dimethyl-amido-benzaldehyde  reaction,  introduced 
by  the  late  Professor  Ehrlich,*  possesses  little  chnical  signifi- 
cance. 

Fistula. — Fistula  in  ano  occurs  in  a  small  proportion  of 
cases  of  pulmonary  tubercle,  and  in  our  series  of  263  autopsies 


ON  COMPLICATIONS   OF  PULMONARY  TUBERCULOSIS      57 1 

it  was  only  observed  on  three  occasions.*''     In  our  experience 
the  compHcation  is  almost  entirely  limited  to  males. 

The  same  causes  which  give  rise  to  fistula  in  the  healthy 
subject  may  produce  it  also  in  the  sufferer  from  phthisis.  It 
may  thus  be  sometimes  traced  to  fish  or  rabbit  bones,  or  other 
irritating  objects  in  the  bowel,  or  result  from  the  exposure  of 
the  parts  to  cold  and  wet. 

Two  special  methods  are  described  by  authors  by  which  this 
complication  may  arise — viz. :  (i)  From  tuberculous  infection 
of  the  rectal  mucous  membrane  by  swallowed  sputum  or 
ulcerous  discharges  from  a  higher  portion  of  the  bowel.  A 
local  ulceration  is  thus  set  up,  which,  by  extension  outwards, 
causes  ischio-rectal  abscess.  (2)  In  other,  and  probably  more 
numerous  cases,  the  tuberculous  disease  commences  in  the 
submucosa,  extends  outwards  into  the  ischio-rectal  fossa,  and 
only  later  perforates  the  intestine. 

The  ischio-rectal  abscess  thus  produced  lacks  as  a  rule  the 
acute  inflammatory  symptoms  which  are  generally  associated 
with  the  non-tuberculous  variety  of  the  disease.  It  is,  on  the 
contrary,  often  of  a  chronic  type,  giving'  rise  to  but  few  symp- 
toms, and  it  may  not  be  until  external  rupture  occurs  that 
the  patient  is  led  to  seek  advice. 

Treatment. — Fistula  may  occur  early  in  the  course  of 
phthisis,  when  the  pulmonary  signs  are  but  sHght.  More 
commonly  it  makes  its  appearance  when  the  malady  is  more 
advanced  and  cachexia  already  marked.  In  cases  of  this  kind 
the  complication  becomes  of  secondary  importance,  and,  un- 
less causing  much  additional  suffering  and  exhaustion,  it 
should  not  be  interfered  with  by  operation. 

In  slighter  cases,  each  one  must  be  judged  upon  its  merits. 
If  the  discharge  be  small  in  amount,  the  patient  suffering  little, 
and  the  fistula  causing  but  trifling  inconvenience,  we  should 
not  advocate  surgical  interference;  for  it  must  not  be  for- 
g-otten  that  the  effect  of  the  anaesthetic  and  the  operation  it- 
self exercise  a  depressing  influence  upon  the  patient,  which  is 
not  infrequently  manifested  by  increased  activity  of  chest 
disease.  There  is  some  evidence  also  to  show  that  in  certain 
cases  a  kind  of  alternation  exists  between  the  activity  of  the 
fistula  and  that  of  the  pulmonary  disease — an  old  clinical 
observation  possibly  explained  by  the  recent  researches  of 
Sir  Almroth  Wright. 


572  DISEASES   OF  THE  LUNGS  AND  PLEURA 

There  are  instances,  however,  in  which  the  local  inconveni- 
ence and  suffering-  from  the  fistula  and  the  mental  distress  are 
so  great  as  to  necessitate  some  operative  measures,  and  in 
such  cases  surgical  treatment  must  be  carried  out. 


REFERENCES. 

^  {a)  Refort  on  the  Work  of  the  Pathological  Department  of  the  Bromfton 
Hospital  during  the  Three  Years  April,  igoo,  to  April,  1903,  by 
P.  Horton-Smith  (Hartley),  M.D.,  pp.  19  and  21.     London,  1903. 

(6)  Loc.  cit.,  p.   16. 

(<r)    Loc.    cit.,    p.    14. 

^  "  Intraocular  Tuberculosis,"  by  Walter  H.  Jessop,  F.R.C.S.,  St.  Bar- 
tholofnew^s  Hospital  Reports,  vol.  xli.,  1905,  p.  183. 

^  "  The  Pathology  of  the  Cerebro-Spinal  Fluid,"  by  J.  Graham  Forbes, 
M.D.,  Lavori  e  Riviste  di  Chimica  e  Microscopia  Clinica,  1908,  vol.  i., 
fasc.  ii.,  p.  ij,. 

*  The  Diseases  of  the  Lungs,  by  James  Kingston  Fowler,  M.D.,  and 
Rickman  John  Godlee,   M.S.,   F.R.C.S.,  pp.   358-362.     London,    1908. 

°  "  Lardaceous  Disease,"  by  W.  Howship  Dickinson,  M.D.,  Clifford 
Allbutt's  Sy stein  of  Medicine,  first  edition,  vol.  iii.,  p.  264.     London,  1897. 

^  "  Amyloid  Disease  :  its  Acute  Form  :  Relation  to  Hyaline  Degenera- 
tion :  Cause  :  Early  Diagnosis  and  Treatment,"  by  Alan  B.  Green,  M.A., 
M.B.,  Journal  of  Pathology  and  Bacteriology,  Edinburgh  and  London, 
1901,  p.  184. 

'    [a]    "  The    Kidneys    in    Tuberculosis  :    A    Pathological    and    Clinical. 
Study,"    by    Joseph    Walsh,    M.D.,    Second   Annual    Report    of   the 
Henry  Phipps  Institute,  p.   151.     Philadelphia,  1906. 
[b]  Loc.  cit.,  p.  165. 

*  "  Ehrlich's  Dimethyl(^)-amido-benzaldehyde  Reaction,"  by  H.  W. 
Armit,  M.R.C.S.,  L.R.C.P.,  Transactions  of  the  Pathological  Society  of 
London,  1903,  vol.  liv.,  p.  184;  also  British  Medical  Journal,  1903,  vol.  i., 
P-   549- 


CHAPTER  XLI 

THE  DIAGNOSIS  OF  PULMONARY  TUBERCULOSIS 

In  the  preceding  chapters  we  have  considered  the  various  chni- 
cal  manifestations  of  phthisis  which  may  be  met  with,  and  the 
more  important  complications  of  the  disease.  We  have  seen 
that  in  the  great  majority  of  cases  the  tuberculous  process 
begins  near  the  apices  of  the  lung's,  and  extends  downwards, 
while  the  physical  signs,  not  very  distinct  at  first,  gradually 
become  more  and  more  definite  as  consohdation,  softening- 
and  cavity  formation  succeed  each  other,  until  finally  the 
patient  presents  the  classical  picture  of  advanced  disease  so 
graphically  portrayed  for  us  by  Aretaeus^  many  centuries  ago. 
In  such  a  case  diagnosis  is  no  longer  difficult.  But,  in  order 
that  treatment  may  be  effective,  it  is  of  the  first  importance 
that  the  disease  should  be  recognised  at  an  early  stage,  and 
how  this  may  be  effected  we  propose  to  consider  in  the  present 
chapter. 

Upon  the  methods  of  physical  diagnosis  which  we  have 
already  discussed  great  reliance  may  be  placed.  With  com- 
mencing consolidation,  which  is  associated  with  effacement  by 
collapse  or  thickening,  of  the  vesicular  tissue  of  the  lung  over 
the  affected  area,  we  obtain  a  slight  impairment  of  the  per- 
cussion resonance,  and  with  it  a  weakening  of  the  breath- 
sound  and  a  partial  or  complete  suppression  of  its  vesicular 
quality,  the  expiratory  murmur  becoming  more  prolonged 
than  natural.  As  the  consolidation  becomes  more  dense,  the 
breath-sounds  gradually  assume  a  bronchial  character,  both 
inspiratory  and  expiratory  sounds  being  conducted  from  their 
tracheo-glottic  source.  Vocal  resonance  and  vocal  vibrations 
are  both  increased,  and  a  few  moist  crepitations  may  become 
audible.  It  is  with  the  inspiration  after  a  cough  that  these 
crepitations  are  first  disclosed. 

Should  early  apical  signs  such  as  these  be  found  in  patients 
who  have  sought  advice  complaining  of  cough,  wasting,  or 
perhaps  a  slight  haemoptysis,  they  are  of  diagnostic  impor- 

573 


574  DISEASES   OF  THE  LUNGS   AND  PLEURA 

tance.  A  rise,  it  may  be  only  slight,  of  evening  temperature 
is  usually  already  to  be  detected,  and  the  patient  will  generally 
complain  of  some  night  sweating.  Later  on,  when  softening 
of  the  tuberculous  foci  in  the  lung  takes  place,  bacilli  will 
make  their  appearance  in  the  sputum;  and  even  in  a  case  in 
which  the  expectoration  is  scanty  it  may  still  be  possible  to 
find  some  in  the  small  specks  brought  up  in  the  early  morning 
on  first  waking,  which  should  be  examined  patiently  for 
several  days  in  succession. 

If  tubercle  bacilli  be  not  found  by  ordinary  staining,  con- 
centration methods  must  be  employed.     These  are  of  various 
kinds,  but  their  object  is  the  same,  namely,  by  the  liquefaction 
of  a  considerable  quantity  of  sputum  (5  to  20  c.c.)  and  its 
subsequent  treatment  by  centrifugalisation  or  otherwise,  to 
obtain  a  film  in  which  all  the  bacilli  are  collected.     The  anti- 
formin  method  of  Uhlenhuth  and  Xylander'  is  that  most  gen- 
erally employed  at  the  present  time.     This  consists  in  treat- 
ing in  a  test  tube  equal  quantities  of  sputum  and  15  per  cent, 
antiformin — a  solution  in  definite  proportions  of  sodium  hypo- 
chlorite and  sodium  hydrate.     The  mixture  is  shaken  from 
time  to  time  and  soon  becomes  homogeneous.     It  is  then 
centrifugalised  and  the  supernatant  liquid  pipetted  off.     The 
deposit  is  washed  in  normal  saline  solution  and  again  cen- 
trifugaHsed.     The  supernatant  fluid  is  once  more  pipetted  off, 
and  films,  made  from  the  deposit,  are  stained  by  the  Ziehl- 
Neelsen    method.     We    have    on    several    occasions    known 
tubercle  bacilli  to  be  thus  discovered  when  ordinary  methods 
several  times  repeated  had  failed. 

The  antiformin  method  may  also  be  applied  to  the  stools, 
and  when  sputum  cannot  be  obtained,  as  in  children  and  those 
who  swallow  their  expectoration,  the  stools  may  be  examined, 
and  it  is  sometimes  possible  to  discover  the  bacilli  in  the  fseces. 
In  a  little  girl  under  our  care  at  the  Brompton  Hospital,  who 
presented  signs  and  symptoms  of  advancing  tuberculosis  of 
the  lungs,  but  without  expectoration,  tubercle  bacilli  were  in 
this  way  easily  demonstrated. 

The  presence  of  tubercle  bacilli  in  the  sputum  makes  the 
diagnosis  sure,  but  we  must  not  forget  that  their  presence  also 
indicates  that  the  disease  is  no  longer  in  its  earliest  stage,  but 
that  softening  of  the  pulmonary  focus  has  occurred,  and  that 
a  case  of  "closed"  has  been  converted  into  one  of  "open 


THE   DIAGNOSIS   OF   PULMONARY   TUBERCULOSIS         575 

tuberculosis."  It  is  pertinent,  therefore,  to  ask  whether  we 
have  any  other  methods  of  diagnosis  which  may  be  made  use 
of  in  the  recognition  of  those  very  early  cases  of  "  closed  " 
tuberculosis  in  which  the  physical  signs  may  not  be  clear,  the 
symptoms  are  slight  and  indefinite,  and  in  which  no  tubercle 
bacilli  have  yet  made  their  appearance.  Let  us  consider  the 
following : 

X-Ray  Examination. — In  most  X-ray  photographs  in  the 
healthy  adult  the  rays  reveal  an  irregular  shadow  at  the  hilum, 
sometimes  with  certain  deeper  points  of  shading',  these  appear- 
ances indicating  old  lesions,  tuberculous  or  other,  of  the  bron- 
chial glands,  with  areas  of  calcareous  degeneration.  From 
this  central  shadow  there  radiates  through  the  lung  a  delicate 
arborisation  corresponding  to  vessels  and  bronchi,  among 
which  the  main  trunks  passing  to  the  upper  and  lower  lobes 
stand  out  more  conspicuously.  In  cases  of  phthisis  in  the 
adult  these  appearances  are  visible,  but  in  addition  there  is 
often  seen  a  mottled  shading  which  is  characteristic  of  well- 
developed  pulmonary  tuberculosis,  these  shadows  having, 
when  in  focus,  a  somewhat  woolly  outhne  when  the  disease 
is  active  and  becoming  more  defined  when  it  is  of  old  standing. 
Such  mottling  is  not,  however,  an  early  sign  of  phthisis,  and 
is,  in  our  experience,  not  seen  without  there  being  some 
physical  signs  to  indicate  the  disease. 

In  the  adult  we  have  seen  reason  to  believe  (p.  471)  that  it 
is  rare  for  infection  of  the  lung  to  spread  from  the  bronchial 
glands  into  the  substance  of  the  lung,  where  the  changes 
would  be  beyond  the  reach  of  physical  examination,  and  the 
X-ray  appearances  held  to  indicate  this  form  of  "hilum  tuber- 
culosis" are  not  to  our  mind  convincing.  On  this  point  fur- 
ther correlation  of  X-ray  appearances  and  post-mortem  find- 
ings is  much  needed.  We  have  ourselves  rarely  met  with 
cases  of  phthisis  which  do  not  quite  early  give  physical  signs 
at  the  apices  of  the  lungs. 

Passing  to  the  screen  examination,  we  not  infrequently 
find  a  restricted  movement  of  the  diaphragm  on  the  affected 
side,  and  this  was  held  a  few  years  ago  to  be  the  earliest  sign 
of  pulmonary  tuberculosis.  It  is  now  recognised,  however, 
that  this  sign  may  occur  under  many  conditions  apart  from 
phthisis,  and  its  diagnostiq  value  is  not  therefore  great. 

Another    sign  observed    on    the    screen    is    a    diminished 


5/6  DISEASES   OF  THE  LUNGS   AND  PLEURA 

translucency  at  one  or  other  apex  and  a  failure  of  this  portion 
of  the  lung  to  light  tip  on  deep  inspiration  to  the  same  degree 
as  its  fellow  on  the  unaffected  side.  This  sign  may  be  noticed 
in  a  proportion  of  early  cases,  but  not  in  our  experience 
before  the  occurrence  of  physical  signs;  moreover,  it  is  not 
always  easy  to  be  certain  of  the  X-ray  appearances,  and  we 
must  remember,  too,  that  tuberculosis  is  not  the  only  patho- 
logical condition  which  can  produce  such  altered  appearances. 

An  X-ray  examination  is,  however,  of  assistance  in  certain 
cases.  Thus  in  pulmonary  tuberculosis  associated  with  em- 
physema, in  which  the  physical  signs  of  the  former  are  to 
some  extent  masked,  the  rays  may  indicate  more  extensive 
disease  than  had  been  anticipated.  We  have  known  them  also 
to  explain  persistent  pyrexia  in  a  case  suspected  at  first  to  be 
one  of  acute  pulmonary  tuberculosis,  by  revealing  a  marked 
enlargement  of  the  bronchial  glands,  which  were  almost  cer- 
tainly infected  with  tubercle.  Occasionally  also  a  large,  deep- 
seated  area  of  tuberculous  disease  may  be  discovered  by  the 
rays  before  the  occurrence  of  physical  signs  or  the  presence 
of  bacilli  in  the  sputum,  as  in  the  case  which  we  shall  shortly 
describe. 

Our  experience,  then,  is  that  in  early  cases  of  phthisis  the 
diagnosis  can,  as  a  rule,  be  made  by  physical  signs  before  the 
appearance  of  characteristic  X-ray  changes.  Yet,  seeing  that 
cases  of  abnormal  type  do  occur  from  time  to  time  in  which 
an  X-ray  examination  is  of  value,  the  method  is  one  which 
should  not  be  neglected  in  a  case  of  difficulty  or  doubt,  the 
X-ray  findings  being  always,  however,  interpreted  in  the  light 
of  the  patient's  signs  and  symptoms.  And  let  us  insist  on  the 
importance  of  the  examination  being  in  expert  hands. 

The  following  case,  in  which  the  X-rays  proved  helpful  in 
detecting  a  deep-seated  area  of  tuberculous  consoHdation 
before  the  occurrence  of  physical  signs  or  the  discovery  of 
tubercle  bacilli  in  the  sputum,  appears  worth  recording,  though 
we  must  emphasise  that  the  case  is  an  exceptional  one,  and  the 
character  and  position  of  the  lesion  most  unusual : 

L.  P.,  aged  twenty-three,  a  shop-assistant,  came  under  the  care 
of  one  of  us  as  an  out-patient  at  the  Brompton  Hospital  in  August, 
1903,  complaining  of  loss  of  weight  and  a  feeling  of  weakness  during 
the  previous  two  months.  He  had  no  cough  or  expectoration.  His 
saliva  had  once  been  streaked  with  blood,  but  there  had  been  no  true 


THE   DIAGNOSIS    OF   PULMONARY   TUBERCULOSIS         577 

haemoptysis.  His  temperature,  taken  at  the  time  of  his  visit,  was 
98-4° ;  his  weight,  10  stone  65  pounds.  An  examination  of  the  chest 
revealed  no  abnormal  physical  signs,  and  the  case  was  regarded  as 
probably  one  of  debility  only,  though  his  aspect  and  slender  build 
gave  cause  for  some  anxiety.  During  the  next  three  months  his 
weight  was  maintained ;  his  temperature  was  not  raised,  and  no 
abnormality  was  revealed  by  physical  examination.  A  little  phlegm 
was  hawked  up,  but  no  bacilli  could  be  found  in  it. 

On  November  30  the  weight  was  10  stone  25  pounds,  a  loss  of 
35  pounds  during  the  preceding  fortnight.     His  temperature  was  98°. 

On  December  14  slight  cough  and  morning  expectoration  were  com- 
plained of,  but  still  no  bacilli  could  be  discovered.  An  X-ray  examina- 
tion was  made  on  this  date  by  Dr.  Greg,  who  reported  a  somewhat 
dense  shadow  extending  from  the  clavicle  to  the  fourth  rib — most 
dense  at  the  centre  of  its  area  ;  the  movements  of  the  diaphragm  on  the 
left  side  were  also  slightly,  though  definitely,  restricted.  The  appear- 
ance of  the  shadow  is  shown  in  the  accompanying  diagram  (Fig.  56). 

In  the  light  of  this  report,  the  chest  was  again  examined,  but  the 
only  abnormality  discovered  was  some  cogged-wheel  respiration  on 
the  left  side,  heard  most  markedly  over  the  region  of  the  shadow. 

On  February  22,  1904,  his  weight  had  risen  to  10  stone  6|  pounds, 
and  he  ceased  attending  for  a  time. 

On  May  16  he  reappeared,  having  kept  pretty  well  during  the  inter- 
val. His  weight  was  now  10  stone  115  pounds.  He  still  had  a 
slight  cough  and  a  little  phlegm.  His  chest  on  physical  examination 
showed  no  new  development.  On.  June  12  the  X-ray  examination 
showed  the  shadow  to  be  less  dense,  and  less  distinctly  outlined,  and 
perhaps  a  trifle  larger.  On  this  date  tubercle  bacilli  were  found  for 
the  first  time  in  the  sputum. 

The  patient  was  not  seen  again  until  October,  when  he  was  found 
to  have  gone  downhill  rapidly.  He  was  still  at  work,  but  his  cough 
was  troublesome,  and  he  brought  up  every  morning  half  a  teacupful 
of  phlegm  ;  he  had  had  also  several  serious  attacks  of  hemoptysis. 
He  looked  thin  and  pallid,  and  his  weight  had  fallen  to  9  stone 
3^  pounds.  Definite  physical  signs  were  now  present  in  the  chest. 
The  note  was  impaired  from  the  left  apex  down  to  the  level  of  the 
third  rib,  and  over  this  area  showers  of  fine  crepitation  were  audible 
on  coughing.  The  breath-sounds  were  weaker  over  the  same  region, 
and  above  the  clavicle  were  slightly  bronchial  in  character.  On 
examination  with  the  X-rays,  the  area  of  opacity  was  found  to  be  a 
little  greater  and  less  circumscribed  than  when  it  was  first  observed 
nearly  a  year  ago,  and  to  have  assumed  the  typical  mottled  appearance 
so  suggestive  of  well-developed  pulmonary  tuberculosis.  The  patient 
after  this  date  ceased  attending,  and  we  have  been  unable  to  ascertain 
the  further  progress  of  his  disease. 

The  case  which  we  have  described  is  of  interest.  It  was 
apparently  one  in  which  a  comparatively  large  area  of  lung 

37 


5;8 


DISEASES   OF   THE  LUNGS    AND   PLEURA 


had  become  the  seat  of  tuberculosis,  not  in  the  usual  situation, 
but  in  the  central  part  of  the  left  upper  lobe,  and  had  then 
undergone  caseation.  From  its  position,  separated  by  air- 
containing"  lung  from  the  chest  wall,  it  failed  to  be  recognised 
by  physical  signs;  but  its  opacity  to  the  X-rays  produced  a 
definite  shadow  some  time  before  tubercle  bacilli  were 
found  in  the  sputum,  and  before  physical  signs  became  evi- 
dent. Such  cases  are,  however,  quite  rare,  and  their  occasional 
occurrence  does  not  alter  our  conclusion  that  only  excep- 


Fig.  56. — Diagram  showing  the  Unusual  Appearances  seen  on  the 
Screen  in  a  Case  of  Early  Pulmonary  Tuberculosis. 

tionally  can  we  expect  assistance  from  the  X-rays  in  the  early 
diagnosis  of  phthisis. 

The  Tuberculin  Test.— This  test  depends  upon  the  fact  that 
a  person  already  infected  with  tubercle  is  much  more  sensitive 
to  a  dose  of  tubercuhn  than  is  a  healthy  person.  The  test 
may  be  applied  in  several  ways,  of  which  we  shall  consider  the 
following :  (a)  by  the  injection  of  old  tuberculin  under  the 
skin  in  the  manner  originally  suggested  by  Professor  Koch 
(the  subcutaneous  test);  (b)  by  its  inoculation  into  the  skin 
(von  Pirquet's  cutaneous  test) ;  (c)  by  instilling  the  tuberculin 


THE   DIAGNOSIS   OF   PULMONARY   TUBERCULOSIS         5/9 

into  the  conjunctival  sac  (the  conjunctival  test  of  Wolff-Eisner 
and  Calmette). 

The  Subcutaneous  Test. — Of  the  various  tests,  this  is  the 
oldest  and  the  most  important.  It  should  be  performed  by 
injecting  under  the  skin  at  intervals  of  forty-eight  hours 
increasing  quantities  of  Koch's  old  tuberculin,  w^hen,  if  tuber- 
culosis is  present,  a  reaction  occurs,  manifesting  itself  by  a 
rise  of  temperature  and  generfal  constitutional  symptoms, 
accompanied  often  by  local  swelling  and  redness  of  the  site 
of  inoculation,  and  very  possibly  by  some  focal  symptoms  and 
signs,  which  serve  to  indicate  the  seat  of  the  disease.  It  must 
be  assumed  that  the  preparation  of  old  tuberculin  is  of  uniform 
strength.  It  is  further  necessary  that  in  all  cases  in  which  it  is 
used  the  patient  should  be  under  close  observation,  so  that 
any  rise  of  temperature  or  other  signs  of  reaction  may  be  duly 
noted,  and  for  this  purpose  the  temperature  should  be  taken 
every  four  hours  for  a  few  days  prior  to  the  injection,  so  that 
the  normal  rang-e  may  be  observed.  The  test  should  not  be 
applied  to  febrile  patients  whose  mouth  temperatures  reach 
100°;  a  rise  of  temperature  under  such  conditions  would  be 
difficult  of  interpretation,  and  the  test  itself  might  not  be  with- 
out risk  of  increasing  the  activity  of  the  disease.  The  tuber- 
culin is  best  prescribed  in  cubic  millimetres  (c.mm.),  as  Drs. 
Morland  and  Riviere  have  suggested,  the  cubic  milli- 
metre being  the  amount  of  tuberculin  really  indicated 
by  the  milligram  of  the  older  nomenclature.  The  doses 
required  are  supplied  by  the  chief  chemists  in  small 
sterilised  phials,  each  of  which  contains  the  specified 
quantity  for  one  injection,  properly  diluted  for  use.  The 
doses  usually  given  for  the  adult  are  as  follows :  02  c.mm., 
I  c.mm.,  5  c.mm.,  and  lo  c.mm.  If  the  test  remains  negative 
after  an  injection  of  lo  c.mm.,  tuberculosis  can  be  excluded. 
According  to  our  experience,  a  reaction  does  not,  as  a  rule, 
occur  in  cases  of  suspected  phthisis  until  a  dose  of  5  or  10  c.mm. 
has  been  attained.  If  after  an  injection  the  physician  is  in 
doubt  as  to  whether  a  reaction  has  occurred  or  not,  the  dose 
last  given  should  be  repeated,  not  immediately  increased. 

For  children  the  doses   of  tuberculin   should   be   smaller : 
o-i  c.mm.,  0-5  c.mm.,  2-5  c.mm.,  and  finally  5  c.mm. 

The  injections  are  commonly  made  between  the  shoulder- 
blades,  as  the  skin  is  here  lax,  and  any  local  swelHng  or  red- 


580  DISEASES   OF   THE  LUNGS   AND   PLEURA 

ness  which  may  occur  at  the  site  of  injection — and  with  the 
larger  doses  this  is  not  uncommon — is  but  little  felt.  Other 
sites  may  be  chosen,  however,  such  as  the  skin  over  the  lower 
axillary  region,  or,  if  the  patient  prefer  it,  the  arm.  The 
temperature  after  the  injection  should  be  taken  every  four 
hours,  but  unless  signs  of  a  reaction  occur  it  is  not  necessary 
for  the  patient  to  remain  in  bed.  It  is  perhaps  best  to  give 
the  injection  towards  evening^  so  that,  if  the  result  be  positive, 
signs  may  show  themselves  before  the  patient  rises  next 
morning. 

The  general  reaction  manifests  itself  by  lever,  headache, 
pain  in  the  back  and  limbs,  and  general  feeling  of  malaise  and 
illness,  and  differs  much  in  degree  in  different  subjects.  If 
the  fever  does  not  exceed  ioo"5°,  the  reaction  is  sometimes 
spoken  of  as  "mild";  a  "moderate"  or  "severe"  reaction 
being  denoted  by  a  maximum  temperature  between  100-5° 
and  102°,  and  above  102°  respectively.  As  a  rule,  the  higher 
the  fever,  the  more  marked  are  the  constitutional  symptoms. 
The  temperature  generally  commences  to  rise  some  eight  to 
twelve  hours  after  the  injection,  though  in  some  cases  the 
interval  may  be  less  (Fig.  60),  whilst  in  others  the  reaction  may 
be  delayed  until  the  following  day.  The  rise  is  usually  rapid 
to  the  maximum,  the  fall  more  gradual,  the  normal  tempera- 
ture being  reached  after  twenty-four  or  forty-eight  hours,  or 
in  some  cases  even  later. 

The  following  charts,  taken  from  patients  under  our  care, 
demonstrate  the  varying  temperature  curves  which  may  be 
observed : 




Ju/.v 

Date 

13 

14 

15 

16 

17 

18 

19 

A.  M. 

p.  M. 

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A.M. 

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21.    20  20  3i    21,21, 

20  20  22  20  22  20 

21,    21,   22  22  22  20 

20  20  20  20  20  24 

Fig.  57. — Showing  a  "  Mild"  Reaction  produced  by  an  Injection  of 

10  c.MM.  Old  Tuberculin. 

The  temperature  remained  a  little  raised  for  four  days  before  returning 

finally  to  normal. 


THE  DIAGNOSIS   OF  PULMONARY  TUBERCULOSIS         58 1 


}'eb. 

March 

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26 

27 

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;   \>^': 

Fig.  58. — Showing  a  "  Moderate  "  Reaction  accompanied  by  Increased 
Cough  and  Phlegm,  produced  by  an  Injection  of  5  c.mm.  Old  Tuber- 
culin. 


f'eb. 

March 

Date. 

26 

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p.  M. 

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Fig.  59. — Showing  a  "  Severe  "  Reaction  accompanied  by  Increased 
Cough  and  Pain  over  the  Upper  Portion  of  Both  Lungs,  produced 
BY  an  Injection  of  5  c.mm.  Old  Tuberculin. 


1     n    , 

Jan. 

Feft. 

Date 

27 

26 

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30 

31 

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p.   M. 

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■20  20-20  10  20  20 

Fig. 


60.— Showing  an  Unusually  Severe  Reaction,  produced  by  an 
Injection  of  10  c.mm.  Old  Tuberculin. 


582  DISEASES   OF  THE  LUNGS   AND   PLEURA 

We  may  add  that  no  rise  of  temperature  should  be  con- 
sidered as  a  reaction  unless  it  amounts  to  at  least  1°  F.  above 
the  highest  temperature  recorded  during  the  days  immediately 
preceding  the  injection.  Moreover,  slight  rises,  unless  accom- 
panied by  constitutional  symptoms,  should  be  regarded  with 
suspicion,  and  the  matter  decided  by  a  further  injection  of 
tuberculin,  the  quantity  last  given  being  repeated  before  pro- 
ceeding to  the  higher  doses  in  the  scale. 

A  definite  reaction  to  tuberculin  such  as  we  have  described 
indicates  almost  with  certainty  a  tuberculous  focus  within  the 
body.  A  negative  reaction  to  the  test,  on  the  other  hand, 
unless  the  patient  be  in  the  last  stages  of  phthisis,  and  thus 
unable  to  react — when,  we  may  add,  the  test  should  not  be 
appHed — is  very  strong  evidence  against  the  tuberculous 
nature  of  the  disease. 

The  g'eneral  reaction,  however,  with  which  we  have  been 
dealing,  does  not  do  more  than  demonstrate  the  existence  of 
a  tuberculous  focus  somewhere  in  the  body.  It  does  not  prove 
that  it  is  in  the  lung,  nor  does  it,  as  a  matter  of  fact,  prove  that 
the  focus  is  in  a  condition  of  activity,  seeing  that  the  observa- 
tions of  Madison,^  Franz,*  Max  Beck,*  and  others  prove  that, 
at  least  among  the  working  classes,  latent  lesions  may 
be  revealed  by  the  test  in  from  40  to  61  per  cent,  of  individuals 
who  show  no  sign  or  symptom  of  tuberculosis.  But  should 
the  patient  have  been  suffering  from  cough,  wasting,  or  other 
symptom  suggestive  of  pulmonary  tuberculosis,  with  some 
indefinite  signs  in  the  lung,  it  is  not  unreasonable  to  suppose 
that  the  focus  is  situated  actually  in  the  lung  itself,  and  that 
the  lesion  is  an  active  one.  This  assumption  is  rendered 
almost  certain  if,  as  not  infrequently  happens  with  the  more 
severe  reactions  at  any  rate,  signs  of  a  focal  reaction  in  the 
lung  make  their  appearance.  These  are  manifested  by  pain 
over  the  chest,  increased  cough,  and  possibly  by  the  expectora- 
tion of  a  little  phlegm,  in  which  tubercle  bacilli  may  make 
their  appearance  for  the  first  time.  On  auscultating  the  chest, 
crepitations  are  sometimes  also  heard  at  a  spot  where  before 
the  signs  had  been  indefinite.  These  focal  signs  are  due  to 
the  congestion  and  inflammatory  reaction  which  are  well 
known  to  occur  at  the  seat  of  the  tuberculous  disease  as  the 
result  of  the  injection  of  tuberculin,  and  which  have  been 
demonstrated  so  frequently  in  cases  of  lupus. 


THE   DIAGNOSIS   O^  PULMONARY   TUBERCULOSIS         583 

The  occurrence  of  this  focal  reaction  is  thus  of  great  impor- 
tance, for,  should  it  accompany  the  general  reaction,  it  proves 
the  existence  of  a  tuberculous  lesion  in  the  lung  itself,  and 
enables  the  physician  to  recommend  without  hesitation  impor- 
tant measures  of  treatment,  of  the  necessity  of  which  he  may 
up  till  then  have  been  in  doubt.  In  other  cases  a  negative 
result  to  the  subcutaneous  test  has  enabled  us  to  exclude  the 
presence  of  tubercle,  and  thus  allay  anxiety  and  avoid  unneces- 
sary expense. 

The  tuberculin  test  should  not,  as  we  have  said,  be  used  in 
febrile  cases;  nor,  we  may  add,  in  cases  in  which  there  has 
been  recent  haemoptysis,  owing  to  the  increased  local  conges- 
tion which  results.  It  should  be  withheld  also  in  patients  with 
kidney  disease,  in  those  suffering  from  epilepsy,  and  those 
greatly  debilitated  from  whatever  cause.  Mild  laryngeal 
disease  is  no  contra-indication  to  its  use.  If  care  be  exer- 
cised in  these  respects,  and  in  the  dosage  and  administration 
of  the  tuberculin,  we  believe  that  the  test  may  be  safely  em- 
ployed, and  in  our  own  experience  we  have  never  observed 
harm  to  arise  from  it.  It  should  not,  hozvever,  be  used,  save 
in  those  cases  in  which  more  light  in  diagnosis  is  for  special 
reasons  urgently  needed. 

The  Cutaneous  and  Conjunctival  Test. — In  the  last  edition 
of  this  work  we  considered  in  some  detail  the  cutaneous  and 
conjunctival  tests,  with  which  the  names  of  von  Pirquet  and 
Calmette  are  usually  associated.  Experience  has,  however, 
shown  that  the  cutaneous  test  is  too  dehcate,  responding-  to 
latent  lesions,  and  thus  commonly  giving  a  positive  result  in 
healthy  persons  other  than  infants  and  very  young  children. 
It  is  therefore  of  no  value  in  the  diagnosis  of  phthisis.  The 
conjunctival  test,  besides  being  of  very  uncertain  value,"  is  apt 
to  set  up  serious  conjunctival  trouble,  and  is  not  therefore  to 
be  recommended. 

The  Opsonin  Test.— This  method  of  diagnosis  was  intro- 
duced by  Sir  A.  E.  Wright,'  and  is  based  upon  the  estimation 
of  the  relative  quantity  of  opsonin  present  in  the  serum  of  the 
suspected  person,  and  a  comparison  of  the  amount  with  that 
observed  in  healthy  individuals.  Into  the  technique  of  the  test 
we  do  not  propose  to  enter  farther  than  to  say  that  it  consists 
in  bringing  into  contact  measured  quantities  of  the  serum  of 
the  patient,   white  blood-corpuscles   from   a  healthy  person, 


584  DISEASES   OF  THE  LUNGS   AND   PLEURA 

and  an  emnlsion  of  tubercle  bacilli,  and  allowing  them  to 
remain  in  the  incubator  at  37°  C.  for  a  quarter  of  an  hour.  At 
the  end  of  this  period  a  film  is  made,  which  is  stained  with 
carbol-fuchsin,  decolourised  with  acid,  and  then  counterstained 
with  methylene  blue,  when  the  number  of  bacilli  taken  up  by 
the  leucocytes  is  counted.  A  similar  procedure  is  then  carried 
out,  using  the  serum  of  a  healthy  person  (or  a  mixed  serum 
from  several  healthy  people)  as  a  control,  and  the  number  of 
bacilli  within  the  cells  again  enumerated.  The  figure  obtained 
in  the  case  of  the  patient's  serum,  divided  by  that  obtained 
when  using  the  control  or  healthy  serum,  constitutes  the 
"  opsonic  index,"  and  gives  the  measure  of  the  quantity  of 
opsonin  present  in  the  serum,  which,  it  is  thought,  so  affects 
the  bacilli  as  to  enable  them  to  be  absorbed  with  readiness  by 
the  white  corpuscles. 

It  has  been  shown  by  Professor  Bulloch  and  others  that  the 
index  among-  healthy  persons  varies  between  0*8  and  i-2,  and 
that  consequently  any  figures  within  these  limits  must  be 
regarded  as  coming  within  the  normal.  It  has  also  been 
demonstrated  that  an  injection  of  tuberculin  produces  a 
marked  variation  in  the  index,  causing  a  rise  or  fall,  according 
as  a  positive  or  negative  phase  has  been  produced.  Turning 
to  pulmonary  tuberculosis,  the  work  of  Dr.  Inman  and  others 
has  shown  that  in  active  disease,  even  when  the  patient  is  at 
rest,  the  index  often  varies  markedly  from  day  to  day,  swing- 
ing on  either  side  far  beyond  the  normal.  The  patient  is  pre- 
sumably absorbing  from  his  focus  of  disease  irregular  quan- 
tities of  tuberculin,  and  is  living  in  a  succession  of  positive  and 
negative  phases,  that  is  to  say,  of  depression  or  exaltation  of 
the  opsonic  index.  This  variation  of  the  index  is  weh  seen 
in  the  following  chart  (Fig.  61),  from  a  patient  in  the  Brompton 
Hospital  suffering  from  active  pulmonary  tuberculosis,  ob- 
served by  Dr.  Inman,  which  we  have  taken  from  his  Weber- 
Parkes  Prize  Essay  for  1909. 

Such  cases  of  active  disease  are  usually,  however,  already 
diagnosed  on  other  grounds,  and  these  spontaneous  changes 
in  the  index  when  at  rest  become,  therefore,  of  comparatively 
little  value  for  purposes  of  diagnosis.  In  early  stages  of  the 
disease,  on  the  other  hand,  the  opsonic  index  is  much  more 
stable.  In  a  certain  proportion  of  cases  of  phthisis,  as  in 
other  varieties  of  local  tuberculosis,  the  index  may  be  low. 


THE   DIAGNOSIS   OF   PULMONARY   TUBERCULOSIS 


585 


and  if  sufficiently  below  the  limits  of  health  this  fact  may 
become  of  diagnostic  importance ;  but  in  other  patients  the 
index  under  ordinary  conditions  may  be  within  the  Hmits  of 
health.  Under  such  circumstances,  however,  Dr.  Inman  has 
shown  that  active  exercise,  such  as  hard  walking  for  an  hour 
or  manual  labour,  often  produces  a  variation  in  the  index,  a 
fall  or  rise  beyond  the  normal,  owing,  very  probably,  to  an 
auto-inoculation  of  tuberculin  from  the  focus  of  disease.  In 
healthy  persons  no  such  variation  is  produced.     These  facts 


Dote 

March. 

4 

5 

6 

r 

ft 

9 

10 

1-7 

1-9 

1-5 
1-4 
1-3 
1-2 
J-1 
1 
0-9 
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0-7 
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/ 

Av 

/ 

/    N 

/ 

/ 

\ 

i 

A 

\ 

f 

/\ 

\ 

1 

7 

/        ^ 

x/ 

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^ 

0-3 

Fig.  61. — Chart  showing  the  Variations  in  the  Opsonic  Index  of  a 
Patient  suffering  from  Active  Pulmonary  Tuberculosis  when  at 
Rest  in  Bed  (Dr.  Inman). 


are  well  shown  in  the  accompanying  charts  (Figs.  62  and  63) 
from  patients  at  the  Brompton  Hospital  observed  by  Dr. 
Inman,  and  taken  from  his  Weber-Parkes  Prize  Essay. 

Variations  in  the  index  following  exercise  such  as  we  have 
been  describing  are  commonly  observed  in  cases  of  early 
phthisis,  and  when  they  occur,  as  they  often  do,  in  suspected 
cases,  they  may  be  regarded  as  evidence  very  suggestive  of 
the  presence  of  a  tuberculous  focus,  a  focus,  moreover,  not 
latent  like  those  revealed  in  many  cases  by  the  tuberculin  test, 
but  one  which  is  active,  and  from  which  toxines  are  being 
absorbed,  and  which  therefore  requires  treatment.  This  con- 
clusion has  received  support  by  carefully  following  up  certain 
of  the  patients  at  the  Brompton  Hospital  who  had  given  sus- 
picious physical  signs,  and  who  had  yielded  a  positive  result 


586 


DISEASES   OF   THE  LUNGS   AND   PLEUR.E 


to  the  opsonin  test.  In  twenty  of  these  patients  repeated 
examination  of  such  sputum  as  could  be  obtained  was  made, 
and  in  nine  of  them  tubercle  bacilli  were  eventually  discovered 
before  they  left  the  hospital. 


1-7 
1-6 
1-5 
14 
1-3 
1-2 
11 
I 
0-9 
0-8 
0-7 
0-6 
0-5 
04 
03 

9  a.m. 

11  a.m. 

12-0 

12-45praj 

N 

-^ 

- — S 

Pa.m. 

lia.rn. 

120 

12-4-5PUJ1 

^j^ 

Fig.  62. — Showing  that  in  He.-\lthy  People  Active  Exercise  producer 
NO  Vari.\tion  in  the  Opsonic  Index  (Dr.  Inman). 

Between  11  a.m.  and  12  an  hour's  hard  walking  exercise  was  taken. 


4  p.m. 

5p.m. 

6p.in. 

Tp.in. 

lOpm. 

11  p.m. 

120 

12-30p.m 

1-7 
1-6 
1-5 
1-4 
1-3 
1-2 
11 
1 
0-9 
08 
0-7 
00 
0-5 
0-4 
0-3 

Patit 

atu^ 

;and 

betive^ 

en  11a 

m. 

Pat  I 

e/itA 

eptin 

bed. 

and! 

Itooh 

anti 

?arsl 

ia.rd 

walkl 

iiQ  e^ 

lercu 

>e. 

^^ 

.... 

^ 

/ 

/ 

■    &•  — 

^- 

.....«/... 



©^ 

Fig.  63. — Showing,  in  the  Case  of  a  Patient  suffering  from  Early 
Pulmonary  Tuberculosis,  an  Index  within  the  Normal  so  long  as 
the  Patient  remained  at  Rest,  but  Marked  Abnormal  Variation 
produced  by  Exercise  (Dr.  Inman). 

Other  evidence  of  the  reliability  of  the  test  is  afforded  by 
the  fact  that,  as  Dr.  Inman  has  shown,  and  as  we  have  pointed 
out  elsewhere,  the  variations  in  index  produced  by  exercise 


THE  DIAGNOSIS   OF  PULMONARY  TUBERCULOSIS         587 

may  be  observed  to  cease  when,  as  the  result  of  treatment, 
complete  arrest  of  the  disease  has  been  attained. 

We  have  now  to  ask  ourselves  how  far  the  opsonin  test 
which  we  have  been  discussing,  and  which  we  believe  may  be 
relied  upon  in  the  hands  of  observers  well  accustomed  to  its 
use,  is  fitted,  by  reason  of  the  difficulties  of  its  technique  and 
other  causes,  for  general  adoption.  In  this  connection  we 
must  draw  attention  to  some  interesting-  observations  by  Dr. 
E.  C.  Hort,*  who  sent  to  various  pathologists  of  proved  ex- 
perience specimens  of  blood  drawn  at  the  same  time  from  cer- 
tain patients,  and  then  compared  the  indices  obtained.  These 
showed  in  many  cases  gTeat  variation.  To  take  one  example, 
that  of  a  patient  suffering  from  pulmonary  tuberculosis  with 
well-marked  physical  signs,  and  with  tubercle  bacilli  in  the 
sputum,  the  opsonic  indices  returned  by  three  observers  were 
as  follows:  (a)=0'88;  (b)=i-iy  and  i'34  (two  specimens  of 
the  same  blood);  (c)  =  2-^,4.  Two  observations  were  thus 
within  normal  limits;  the  other  two  were  abnormal,  and 
pointed  to  a  diagnosis  of  tuberculosis.  The  difference 
between  the  highest  and  the  lowest  indices  amounted  to  as 
much  as  1-46.  We  have  seen  the  same  discrepancy  in  observa- 
tions from  the  same  specimen  of  blood  made  by  three  observers 
in  a  case  in  which  there  was  no  tuberculosis  present.  In  view 
of  such  results,  we  can  only  conclude  that,  though  the  method 
appears  valuable  in  the  hands  of  a  very  limited  body  of  experts, 
it  is  not  suitable  for  general  employment. 

It  would  be  interesting  to  ascertain  the  relative  phagocytic 
power  in  groups  of  persons  reputed  to  be  more  or 
less  susceptible  to  tuberculosis,  such  as  town  dwellers,  country 
dwellers,  those  living  under  conditions  of  overcrowding  in 
various  degrees,  alcoholics,  feeble-minded,  epileptics,  diabetics 
and  the  insane,  as  giving  insight  as  to  the  mechanism  of  their 
proclivity  to  the  disease. 

Other  Specific  Tests.— We  may  now  briefly  refer  to  certain 
other  specific  tests  for  the  presence  of  tuberculosis,  which, 
like  the  opsonic  test,  depend  upon  the  detection  in  the  patient's 
blood  of  various  specific  substances  produced  in  response  to 
the  invasion  of  the  tissues  by  the  tubercle  bacillus.  They  are 
of  great  scientific  interest,  but  cannot  be  said  to  be  as  yet  of 
much  practical  importance.     Among  them  we  may  mention  : 

(a)  The  C omplement-Fixation  Test. — This  test,  in  the  words 


588  DISEASES   OF  THE  LUNGS   AND  PLEURA 

of  Dr.  Inman,  depends  upon  the  fact  that  if  a  foreign  albumin 
be  introduced  into  an  animal,  specific  antibodies  are  produced 
and  can  be  demonstrated  in  the  blood.  Bacteria  are  such 
foreign  albumins,  and  so  are  red  blood-corpuscles.  It  is  due  to 
this  latter  fact  that  the  so-called  complement-fixation  test  has 
been  made  possible. 

Solution  of  red  cells  may  be  produced  by  bringing  them 
into  contact  with  the  serum  of  an  animal  previously  injected 
with  the  same  type  of  red  cells,  so  long  as  a  sufficient  amount 
of  complement,  a  substance  normally  present  in  blood,  is 
added.  In  the  process  union  takes  place  between  complement, 
red-cell-antibody  and  red  cell.  The  mixture  is  known  as  a 
"  Hasmolytic  system." 

If  tubercle  bacilli  are  brought  into  contact  with  a  serum  con- 
taining antibodies  to  the  tubercle  bacillus,  and  a  sufficient 
amount  of  complement  is  added,  union  takes  place  between 
the  complement,  tubercle  antibodies  and  tubercle  bacilli. 

The  complement-fixation  test  consists  in  bringing'  together 
tubercle  bacilli,  the  patient's  serum  and  complement.  After  a 
suitable  lapse  of  time,  to  allow  of  union  taking  place  in  the 
event  of  tubercle  antibodies  being  present  in  the  patient's 
serum,  red  cells  and  red-cell-antibodies  are  added.  In  those 
tubes  containing  serum  which  possesses  tubercle  antibodies 
no  haemolysis  can  take  place,  for  the  necessai*y  complement  is 
already  "  fixed  "  in  the  combination — complement,  tubercle 
anti-body  and  tubercle  bacillus.  The  reaction  is  then  said  to 
be  positive. 

The  test  has,  however,  not  proved  of  much  value  in  practice, 
since  as  Dr.  Inman,"  Dr.  Radchffe,'"  and  others  have  shown, 
it  is  negative  in  a  certain  proportion  of  early  cases  of  phthisis, 
and  as  the  late  Dr.  Meek"  has  proved,  it  may  remain  positive 
in  patients  with  arrested  disease  who  have  been  free  from 
symptoms  and  in  excellent  health  for  several  years,  showing 
that  a  positive  reaction  does  not  necessarily  indicate  active 
disease. 

(b)  The  Precipitin  Test  and  (c)  the  Cobra  Venom  Test,^^ 
which  we  described  in  our  last  edition,  possess  also  a  scientific 
rather  than  a  practical  value. 

(d)  The  Agglutination  Test,  which  has  been  found  so  valu- 
able in  typhoid  fever,  was  applied  to  tuberculosis  by  Professors 
Arloing  and  Courmont"^  some  years  ago,  and  they  have  re- 


THE   DIAGNOSIS   OF   PULMONARY   TUBERCULSSIS         589 

corded  several  successful  results  in  a  series  of  papers  dealing 
with  this  subject.  In  other  hands,  including  our  own/*  the 
method  has  not  been  found  to  give  reliable  results  in  prac- 
tice, and  we  cannot  therefore  at  present  recommend  it.  If, 
however,  the  difficulties  in  obtaining^  a  culture  yielding  a  satis- 
factory emulsion  of  tubercle  bacilli  can  be  overcome,  the  possi- 
bilities of  the  test  are  great. 

Although  these  tests  must  for  the  present  be  regarded  as 
mainly  of  laboratory  interest,  they  are  nevertheless  of  value 
in  helping  to  deepen  our  insight  into  the  intimate  pathology 
of  the  disease  and  the  modus  of  its  immunity,  and  probably  in 
furnishing  some  clue  to  its  prophylaxis  and  treatment  in  the 
future. 

Conclusion. — We  may,  in  conclusion,  sum  up  the  main  facts 
with  which  we  have  dealt  in  this  chapter,  and  indicate  the  pro- 
cedure which  we  should  adopt  in  arriving-  at  a  diagnosis  in  any 
doubtful  case  of  pulmonary  tuberculosis. 

The  aspect  of  the  patient  is  important,  and  careful  inquiry 
should  be  made  into  the  history  of  the  illness,  including  such 
symptoms  as  coug^h,  loss  of  weight,  and  sweating.  The 
existence  of  pyrexia  is  of  great  moment,  and  its  presence  or 
absence  must  be  definitely  decided  by  a  night  and  morning 
record  of  the  temperature  for  a  period  of  a  week  or  more,  if 
necessary.  The  chest  should  be  carefully  examined,  and  great 
stress  must  be  attached  to  abnormal  physical  signs,  such  as 
slight  impairment  of  note  at  one  apex  and  weak  or  harsh 
breathing,  with  or  without  a  few  moist  sounds  after  cough, 
signs  which  are  commonly  observed  quite  early  in  the  disease. 
Speaking  from  our  own  experience,  we  may  say  that  a  history 
such  as  we  have  indicated,  if  accompanied  by  slight  pyrexia 
and  by  abnormal  apical  signs,  is  almost  diagnostic  of  pul- 
monary tuberculosis,  and  the  examination  of  the  sputum  but 
confirms  the  conclusion. 

Nevertheless,  in  all  cases  the  expectoration  should  be 
examined,  and  the  diag-nosis,  upon  which  far-reaching 
and  expensive  methods  of  treatment  may  depend,  placed, 
if  possible,  beyond  doubt.  For  this  purpose  it  is  best 
to  have  the  early-morning  sputum  tested  for  tubercle  bacilli  by 
ordinary  methods  of  staining  on  three  successive  days;  if  the 
result  be  negative,  the  antiformin  or  some  other  concentration 
method  should  then  be  employed.     In  most  cases  of  this  kind, 


590  DISEASES    OF   THE   LUNGS   AND   PLEURA 

even  if  it  be  stated  that  there  is  no  sputum,  a  Httle  can  be 
obtained  if  the  patient  is  directed  to  carefully  collect  any  par- 
ticles which  he  may  cough  up  in  the  early  morning-  on  first 
waking,  aided  if  need  be  by  a  few  doses  of  an  expectorant 
mixture.  In  children  who  swallow  all  sputum  it  is  sometimes 
possible  to  detect  the  bacilli  in  the  stools,  which  in  such  cases 
should  be  examined  by  the  antiformin  method.  We  have 
known  this  test  prove  successful. 

Should  it  not  be  possible  to  demonstrate  the  presence  of 
tubercle  bacilli,  even  after  the  most  rigorous  search,  and  the 
diagnosis  remains  seriously  in  doubt,  further  tests  may  be  em- 
ployed. In  some  cases  help  may  be  derived  from  the  X-rays; 
but  as  a  rule  in  early  cases  of  phthisis  too  much  must  not  be 
expected  from  this  method  of  examination,  which  is  by  no 
means  free  from  fallacies. 

Of  some  assistance  is  a  determination  by  a  skilled  observer 
of  the  opsonic  index  before  and  after  exercise,  when  in  many 
cases  of  tuberculosis  an  excursion  beyond  the  normal  can  be 
obtained.  But,  for  reasons  which  we  have  given,  the  method 
is  not  suitable  for  general  employment,  and  in  all  cases  the 
results  obtained  must  be  most  carefully  considered  in  the  light 
of  clinical  observation. 

In  afebrile  cases,  when  the  need  for  a  more  certain  diagnosis 
is  pressing,  the  subcutaneous  tuberculin  test  may  be  employed, 
and  for  such  cases  it  should  be  reserved.  The  occurrence  of  a 
general  and  constitutional  reaction  indicates  a  tuberculous 
lesion  somewhere  in  the  body,  but  not  necessarily  an  active 
one;  signs  of  focal  reaction  in  the  lung,  which  are  alone  diag- 
nostic, and  which  must  be  carefully  watched  for,  point  to  pul- 
monary involvement.  In  the  cases  which  we  are  considering 
a  negative  result  to  the  test  would  exclude  the  diagnosis  of 
pulmonary  tuberculosis. 

Von  Pirquet's  cutaneous  reaction  is  too  deHcate  to  be  of 
value;  and  the  conjunctival  test  is  not  to  be  recommended. 


REFERENCES. 

The  Extant  Works  of  Aretczus  the  Caf-podocian,  edited  and  translated 
by  Francis  Adams,  LL.D.,  Sydenham  Society  edition,  p.  309.  London, 
1856. 


THE   DIAGNOSIS    OF   PULMONARY   TUBERCULOSIS         59 1 

^   (i)   "  Antiformin,    ein   bakterienauflosendes    Desinfektionsmittel,"    von 
Prof.     Dr.     Uhlenhuth     und     Dr.     Xylander,     Berliner     Klinische 
Wochenschrift,  1908,  p.  1346.     See  also 
(2)   "  The  Specific  Diagnosis  of   Pulmonary  Tuberculosis,"   by  A.    C. 
Inman,  M.A.,  M.B.,  The  Lancet,  1910,  vol.  ii.,  p.  1747. 

^  Quoted  by  Dr.  Lawrason  Brown,  "  The  Diagnosis  and  Therapeutic 
Use  of  Tuberculin,"  Boston  Medical  and  Surgical  Journal,  July  23,  1908, 
vol.  clix.,  No.  4,  p.  97. 

*  "  Ergebnis  mehrjahriger  Beobachtungen  an  tausend  im  Jahre  1901-02 
mit  Tuberkulin  zum  diagnostischen  Zwecke  injizierten  Soldaten,"  von 
Oberstabsarzt  Dr.  Karl  Franz  (Wien),  Wiener  Klinische  Wochenschrift, 
1909,  p.  991. 

^  "  Ueber  die  Diagnostische  Bedeutung  des  Koch'schen  Tuberkulins," 
von  Dr.  Max  Beck,  Deutsche  Medicinische  Wochenschrift,  March  2,  1899, 

P-   137- 

"  "  The  Conjunctival  Reaction  to  Tuberculin  in  Arthritic  Diseases,"  by 
T.  S.  P.  Strangeways,  Bulletin  of  the  Committee  for  the  Study  of  Sfecial 
Diseases,   Cambridge,    1908,   vol.   ii.,  p.    125. 

'  Studies  on  Immunisation,  and  their  Afflication  to  the  Diagnosis  and 
Treatment  of  Bacterial  Infections,  by  Sir  A.  E.  Wright,  M.D.,  F.R.S., 
p.  150.     London,   1909. 

"  "  Can  Opsonic  Determination  be  relied  on  in  Practice?"  by  E.  C. 
Ilort,  B.A.,  B.Sc,  M.R.C.S.,  Edin.,  British  Medical  Journal,  1909,  vol.  i., 
p.  400. 

^  "The  Diagnosis  of  Pulmonary  Tuberculosis,"  by  A.  C.  Inman,  M.A., 
M.B.,  Oxon,  The  Lancet,  1914,  i.,  p.  1446. 

'"  "  The  Diagnostic  Value  of  the  Complement  Fixation  Reaction  in  Tuber- 
culosis," by  James  Mcintosh,  M.D.,  Paul  Fildes,  M.B.,  B.C.,  and  J.  A.  D. 
Radcliffe,  M.B.,   B.Ch.,  The  Lancet,   1914,  ii.,  p.  485. 

"  "  A  Preliminary  Enquiry  as  to  the  Value  of  the  Complement  Fixa- 
tion Test  in  Tuberculosis,"  by  Leonard  S.  Dudgeon,  F.R.C.P.,  W.  O. 
Meek,  M.B.,  B.S.,  and  H.  B.  Weir,  M.A.,  The  Lancet,  1913,  i.  p.  19. 

'^  [a]  "  La  Reaction  d' Activation  du  Venin  de  Cobra  et  la  Recherche  des 
Anticorps  (Bordet-Gengou)  dans  le  Serum  et  dans  le  Lait  des  Sujets 
Tuberculeux    ou    Suspects     de    Tuberculose,"     par     A.     Calmette, 
L.    Massol,    et    M.    Breton,    Comftes    Rendiis    Hebdomadaires    des 
Seances  et  Memoir es  de  la  Societe  de  Biologie,  Paris,  1908,  vol.  ii., 
p.  648. 
{b)  "  Ehfahrungen  iiber  die  Praktische  Verwertung  der  Komplement- 
bindung  und  anderer   Bakteriologischer  und  Serologischer  Unter- 
suchungen  bei  der  Diagnose  der  Lungentuberkulose,"  von  Dr.  Joh. 
V.   Szaboky,  Zeitschrift  fiir  Tuberkulose,   1909,  Band  xiv.,   Heft  4, 
p.  249. 
(f)  "  On  the  Modern  Procedures  for  the  Early   Diagnosis   of  Tuber- 
culous Infection,"   by  Professor   A.    Calmette,    Transactions   of  the 
Sixth  [Washington]  Congress  on  Tuberculosis,  special  volume,  p.  73 
Philadelphia,  1908. 


592  DISEASES   OF   THE  LUNGS   AND   PLEURA 


13 


"  The  Agglutinating  Power  in  Tuberculous  Patients — Serum  Diag- 
nosis— Serum  Prognosis  "  (with  bibliography),  by  Professor  Paul  Cour- 
mont,  Transactions  of  the  Sixth  International  Congress  on  Tuberculosis 
{Washington),  vol.  i.,  part  i.,  p.  528.     Philadelphia,  1908. 

^''  "  The  Agglutinating  Reaction  in  Cases  of  Pulmonary  Tuberculosis," 
by    P.    Horton-Smith    (Hartley),    M.D.,    and    H.    W.    Armit,    M.R.C.S., 
L.R.C.P.,  Transactions  of  the  British   Congress  on  Tuberculosis,  vol  iii.,. 
p.  151.     London,  1902. 


CHAPTER  XLII 

GENERAL  OBSERVATIONS  ON  THE   PROPHYLAXIS  AND 
TREATMENT   OF   PULMONARY   TUBERCULOSIS 

The  prophylaxis  of  pulmonary  tuberculosis,  generally  speak- 
ing", does  not  essentially  differ  from  that  of  other  diseases;  all 
measures  that  tend  to  increase  constitutional  vigour  also 
diminish  mortality  from  consumption.  On  glancing  through 
the  chapters  on  Etiology,  however,  it  will  be  seen  that  there  are 
certain  conditions,  specific  and  other,  which  especially  favour 
the  occurrence  of  tuberculosis  more  than  of  other  diseases, 
and  that  the  tendency  to  the  disease  is  inherited  in  a  certain 
proportion  of  cases.  By  amending  those  conditions,  especially 
overcrowding,  sedentary  employment,  dusty  occupations  and 
intemperance,  which  favour  the  incidence  of  phthisis,  and  by 
taking  extra  precautions  in  all  cases  of  hereditary  predisposi- 
tion, we  do  the  best  that  can  be  done,  generally  speaking,  in 
the  way  of  prophylaxis. 

There  are  those  amongst  physicians  and  sanitarians  who 
are  still  disposed  to  minimise  hereditary  influence  in  phthisis, 
but  without  doubt,  in  our  opinion,  it  should  be  taken  into 
account  in  considering  the  question  of  marriage.  There  are 
cases  in  which  the  disease  has  manifested  itself  so  strongly  in 
both  the  contracting  families  as  to  make  marriage  absolutely 
undesirable.  Other  less  decided  cases  must  be  considered  on 
their  respective  merits. 

General   Precautions. 

The  child  of  a  consumptive  mother  should  be  weaned  early, 
and  should,  when  possible,  have  a  carefully  selected  wet-nurse. 
If  a  healthy  foster-mother  be  provided,  the  child  should  be 
suckled  entirely  until  eight  or  nine  months  old.  If  the  alterna- 
tive of  a  wet  nurse  be  not  adopted,  careful  hand-feeding  by 

593  38 


594  DISEASES   OF   THE  LUNGS    AND   PLEURA 

humanised  or  other  artificially  prepared  milk  must  be  em- 
ployed, attention  being-  paid  to  an  adequate  provision  of  the 
requisite  vitamines. 

The  hygiene  of  the  nursery  must  be  strictly  looked  to, 
especially  with  regard  to  the  avoidance  of  dust,  the  free  admis- 
sion of  air  without  draughts,  the  provision  of  a  separate  cot 
or  bed  for  the  child,  and  abundance  of  air-space  in  the  night 
nursery.  Milk,  which  should  be  boiled  or  properly  pasteurised, 
must  form  a  large  item  of  the  dietary  throughout  childhood, 
the  other  elements — saccharine,  farinaceous,  nitrogenous  and 
saline — being  duly  provided.  Careful  attention  to  the  skin,  by 
the  use  of  a  tepid  bath  at  least  once  a  day,  warm,  light  all-wool 
underclothing,  loosely  fitting  and  made  to  cover  the  chest  to 
above  the  clavicles,  and  abundant  outdoor  exercise,  are  the 
principal  means  of  securing  sound  health.  The  plan  of  keep- 
ing delicate  young  children  with  naked  legs,  arms,  and  upper 
chest,  with  the  view  of  hardening  them,  is  too  obviously  absurd 
to  need  further  comment.  It  is,  perhaps,  at  the  present  time 
unnecessary  to  add  that  the  nurse  herself  must  be  healthy  and 
strong,  and  free  from  any  suspicion  of  tuberculous  disease. 

At  the  period,  about  the  age  of  eight,  when  children  begin  to 
go  to  school,  the  question  comes  whether  a  day-school  or 
boarding-school  shall  be  selected;  and  in  most  instances  it  is 
decidedly  preferable  that  delicate  boys,  and  perhaps  girls, 
should  be  sent  away  from  home  to  a  carefully-managed  pre- 
paratory school,  than  that  they  should  attend  a  day-school 
from  their  own  homes.  The  divided  responsibiHty  in  matters 
of  hygiene,  food,  clothing  and  the  like,  the  hurried  meals, 
irregularity  in  exercise,  and  increased  exposure  to  cold  and 
wet  in  bad  weather,  which  attendance  at  day-schools  involves, 
are  full  of  risks.  There  is  also  no  doubt  that  dehcate  children, 
from  the  extra  solicitude  which  has  been  necessary  in  rearing" 
them,  become  whimsical  and  mofi3idly  self-conscious  at  about 
this  age,  and  the  regularity  and  discipline  of  school  life  is  good 
for  them.  The  school  should  be  favourably  situated  on  a  well- 
drained  soil  in  the  countr}',  at  the  seaside,  or  in  the  neighbour- 
hood of  the  sea.  The  modified  sea  climate  of  Bournemouth 
suits  children  well,  also  the  high  ground  of  St.  Leonards, 
Ramsgate,  Broadstairs,  Folkestone,  and  many  other  places. 
The  experiment  of  sending  delicate  children  to  the  Swiss 
mountain  resorts  is  of  doubtful  expediency.     It  can  only  be 


TREATMENT  OF   PULMONARY  TUBERCULOSIS  595 

prudently  tried  in  cases  where  abundant  means  will  permit  of 
the  best  conditions  and  supervision. 

Whooping-cough  and  measles  are  antecedent  to  a  large 
proportion  of  cases  of  tuberculosis  in  children,  and  the  utmost 
care  should  be  taken  to  insure  complete  convalescence  from 
these  diseases. 

An  undue  irritability  of  the  lymphatic  glandular  system  is 
often  to  be  observed  in  children  prone  to  phthisis,  and  the 
glands,  when  enlarged,  not  infrequently  undergo  caseation, 
and  remain,  as  it  were,  magazines  of  tuberculous  poison. 
Hence  all  sources  of  gland  irritation,  decayed  teeth,  eczemas, 
eruptions  on  the  scalp,  catarrhal  affections  of  the  bowels  and 
bronchi,  should  be  carefully  and  promptly  treated.  Enlarged 
tonsils  and  adenoids  should  also  receive  attention.  Chicken- 
pox  in  children  often  leaves  behind  troublesome  sores  about 
the  head  and  body,  which  are  very  likely  to  lead  to  glandular 
enlargements,  and  the  utmost  care  should  be  taken  during  this 
disease  to  cleanse  and  protect  all  pustules  which  are  large  and 
likely  to  ulcerate.  In  cases  in  which  the  glands  become 
caseous  and  suppurate  it  is  better,  if  possible,  to  make  a  clean 
excision  of  the  gland,  or  at  least  to  remove  all  caseous  matter 
by  thorough  scraping;  less  scarring  is  thus  caused  than  by 
simple  incision,  and  the  danger  of  infection  of  other  glands  by 
retained  caseous  material  is  removed.  Short  courses  of  cod- 
liver  oil  and  steel  wine  or  Parrish's  Food  should  be  given  to 
delicate  children,  extending  over  three  or  four  weeks,  at  inter- 
vals during  the  winter  and  spring,  and  especially  after  the 
occasional  catarrhs  to  which  they  are  all  liable. 

There  is  some  foundation  in  experience  for  regarding  the 
succeeding  periods  of  seven  years  as  critical  in  matters  of 
health :  there  are  certainly  grouped  about  the  first  and  second 
dentition,  and  the  periods  of  adolescence  and  manhood, 
developmental  changes  and  associated  external  circumstances 
of  life  which  favour  the  occurrence  of  certain  diseases,  and 
peculiarly  of  tuberculosis. 

Between  the  ages  of  fifteen  and  twenty-one  phthisis  is  very 
liable  to  develope  in  those  predisposed,  and  an  opportunity 
may  be  taken  after  the  completion  of  school  education,  or  at 
the  end  of  the  college  career,  to  secure  a  period  of  six  or  twelve 
months  to  be  devoted  to  the  establishment  of  sound  health. 
Many  plans  may  be  devised  with  this  view,  suited  to  the  cir- 


596  DISEASES   OF  THE  LUNGS   AND  PLEUR/E 

cumstances  and  means  of  the  patients  and  their  friends.  A 
long  sea  voyage  with  a  responsible  companion  is  one  of  the 
best  measures,  or  twelve  months'  residence  on  a  farm  in  a 
healthy  part  of  this  country  or  one  of  the  colonies.  With 
girls  it  is  more  easy  to  arrange  a  series  of  visits  to  healthy 
parts  of  the  United  Kingdom  or  abroad,  where  an  outdoor 
life  can  be,  to  a  great  extent,  secured.  The  future  profession 
or  business  of  a  youth  may  during  this  time  be  determined 
upon,  sedentary  pursuits  being  avoided,  and  those  en- 
couraged which  are  associated  with  an  active  outdoor  hfe. 
There  are  some  cases,  however,  and  they  are  not  very  uncom- 
mon, in  which,  with  tuberculous  predisposition,  the  mental 
faculties  are  keen,  whilst  the  bodily  conformation  is  not. such 
as  to  withstand,  or  respond  to,  a  rough  physical  life.  In  such 
cases  a  sheltered  life  is  to  be  recommended,  with  such  pursuits 
as  the  individual  is  best  qualified  for,  and  with  such  precau- 
tions in  the  way  of  hygiene,  exercise,  and  climatic  change  as 
may  be  possible  and  best  adapted  to  the  case.  The  experienced 
physician  can  recognise  in  many  such  cases  that  the  fund  of 
vitality  is  small,  and  that  to  attempt  to  lay  it  out  on  an  ambi- 
tious scale,  with  a  view  to  large  or  long-continued  returns,  is 
to  risk  the  loss  of  the  whole. 

"  Neglected  colds  "  enter  into  the  history  of  a  large  propor- 
tion of  cases  of  phthisis.  The  best  routine  treatment  of  an 
acute  catarrh  in  a  delicate  person  during  the  first  twenty-four 
hours  consists  of  repeated  doses,  at  short  intervals,  of  citrate 
of  ammonia  or  potash,  the  patient  remaining  in  bed  or  in  a 
warm  room.  Frequent  fomentation  of  the  nasal  passages 
with  hot  water  should  be  adopted,  and  a  hot  foot-bath  and  a 
little  Dover's  powder  given  at  night.  Besides  hot-water 
fomentations,  the  local  treatment  of  a  nasal  catarrh  consists 
in  the  use  of  some  antiseptic  inhalation,  spray  or  douche.  The 
vapour  of  equal  parts  of  the  oil  of  eucalyptus  and  eau-de- 
Cologne  may  be  inhaled,  or  the  glycerine  of  thymol  douche 
employed,  or  various  antiseptic  drugs.  In  two  days  quinine 
may  be  commenced,  the  patient  still  remaining  indoors.  After 
about  the  third  or  fourth  day,  when  all  febrile  symptoms  have 
subsided,  a  week's  change  to  some  accessible  seaside  place 
will  commonly  cure  the  catarrh.  Sometimes  at  the  first  onset 
of  the  malady  a  few  fairly  full  doses  of  quinine  will  arrest  it; 
a  combination  with  ammonia  in  the  form  of  the  ammoniated 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  597 

tincture  is  particularly  useful.  Every  effort  must  be  made  to 
prevent  a  catarrh  from  lingering-  or  becoming-  chronic.  In 
all  cases  of  acute  inflammatory  chest  affections  occurring  in 
patients  with  tuberculous  tendency  the  utmost  care  should  be 
taken  to  insure  complete  recovery,  and  it  often  takes  a  long- 
time thoroughly  to  effect  this.  It  is  well,  if  such  attacks  are 
repeated,  to  advise  that  the  ensuing  winter  be  spent  in  taking 
a  voyag'e,  or  at  a  health  resort  adapted  to  the  circumstances 
and  case. 

In  patients  in  whom  there  is  an  inveterate  tendency  to  recur- 
rent catarrh,  whether  influenzal  or  otherwise,  it  may  be  desir- 
able to  ascertain  the  organism  of  infection — Bacillus  catar- 
rhalis,  Pfeiffer's  bacillus,  the  pneumococcus  or  other — and  to 
prepare  a  vaccine  to  be  used  at  appropriate  intervals,  with  a 
view  to  increase  the  resistance  to  these  organisms,  and  thus 
ward  off  the  attack. 


General  Observations  on  Treatment. 

There  is  much  in  the  treatment  of  phthisis  which  is  in  com- 
mon with  the  treatment  of  other  diseases.  The  four  following 
points  should,  however,  be  especially  remembered  with  regard 
to  pulmonary  affections : 

1.  During  respiration  samples  of  the  surrounding  air  are 
constantly  being  brought  into  contact  with  the  extended 
respiratory  surface,  some  portions  of  which  surface  are,  in  the 
cases  under  consideration,  more  or  less  lacerated  or  suppur- 
ating, and  bathed  in  muco-purulent  matters,  ready  to  decom- 
pose, and  abounding-  in  specific  g'erms. 

The  remembrance  of  the  facts  embodied  in  this  statement 
is  enough  to  emphasise  most  strongly  the  importance  of  all 
hygienic  measures  calculated  to  keep  the  air  pure,  and  free 
from  organic  and  inorganic  dust,  and  the  necessity  of  abun- 
dant cubic  space  being  allotted  to  such  invalids,  even  beyond 
the  requirements  of  others. 

2.  All  the  blood  of  the  body  passes  through  the  lungs,  the 
pulmonary  circulation  in  this  respect  balancing  the  systemic. 
From  this  fact  flow  two  or  three  considerations  in  the  treat- 
ment of  phthisis. 

(a)  Any  conditions  which  hurry  the  general  circulation 
cause  an  unduly  proportionate  stress  of  blood-current  through 


598  DISEASES   OF  THE  LUNGS   AND  PLEURAE 

the  lungs,  and  hence  the  importance,  during  active  disease  of 
these  organs,  of  muscular  and  mental  quietude. 

(b)  In  chronic  pulmonary  lesions  in  which  the  disease, 
having  effected  a  certain  measure  of  destruction,  is  stayed,  and 
the  patient  is  regaining  strength,  flesh,  and  colour,  a  point  is 
not  infrequently  attained  when  there  arises  a  relative  systemic 
plethora,  the  blood-volume  and  systemic  metabolism  out- 
balancing the  vascular  and  functional  capacity  of  the  lungs. 
Fresh  pulmonary  hgemorrhage,  congestions,  dyspepsias,  diar- 
rhoea, are  the  natural  consequences  which  tend  to  rectify  this 
perverted  balance,  but  which,  once  started,  rarely  stop  within 
salutary  bounds.  Timely  moderation  in  tonics,  and  a  re- 
consideration of  the  dietary  and  exercise,  will  avert  such 
disasters. 

3.  The  general  circulation  includes  the  local,  and  as  the 
blood-current  passes  through  the  tuberculous  lesions  the 
toxines  of  the  tubercle  bacilli  and  other  attendant  organisms 
are  taken  up  in  greater  or  less  proportion,  according  to  the 
activity  of  the  local  processes  and  the  flow  of  blood.  This 
absorption  of  toxines  under  the  influence  of  the  accelerated 
blood-current  during  active  exercise  may  overwhelm  the  re- 
sistance of  the  patient,  raise  his  temperature,  and  prostrate  his 
nerve-power.  With  perfect  quiescence  absorption  is  lessened, 
the  index  of  resistance  is  raised,  and  the  temperature  lowered. 
In  chronic  lesions  exercise  may  be  so  regulated  by  observa- 
tion of  the  temperature  range  as  to  produce  immunity  by 
securing  duly  adjusted  toxic  absorption.  We  shall  more  fully 
discuss  this  important  matter  in  the  next  chapter. 

4.  Considerable  tracts  of  lung  are  in  health  held  in  reserve 
for  temporary  service  on  occasions  of  unwonted  exertion.  It 
is  the  development  and  bringing  into  daily  action  of  such 
reserves  that  constitutes  a  most  important  element  in  arrest 
of,  or  "recovery"  from,  phthisis.  This  development  can  be 
encouraged  at  the  fitting  time  by  graduated  exercise  on  the 
incline,  by  residence  at  high  altitudes,  or  by  both  combined, 
perhaps  also  by  the  use  of  apparatus  such  as  we  have  referred 
to  when  discussing  "pneumatometry  "  (p.  25).  Mere  expan- 
sion of  lung',  however,  be  it  remembered,  does  not  constitute 
compensatory  development ;  there  must  be  also  increase  of 
capillary  circulation  and  nutrition.  The  cautious  stimulation 
of  blood-pressure  and  respiratory  function  gained  by  regulated 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  599 

exercise  most  efficiently  aids  the  natural  tendency  to  the 
changes  desired. 

The  Hygiene  oe  the  Sick-Room. — This  is  a  matter  of  the 
utmost  importance  in  the  treatment  of  phthisis.  The  dwelling- 
rooms  of  the  patient  should  be  of  good  size,  lofty,  and  well 
ventilated,  with  a  free  exposure  to  the  south  or  south-west, 
and  sheltered  from  the  north  and  east ;  for  the  bedroom  a 
south-east  aspect  is  the  best,  giving-  better  morning  sunlight. 
The  windows  should  be  kept  widely  open  day  and  night. 
French  windows  are  preferable,  as  they  can  be  adjusted  to 
protect  against  any  prevailing  hig"h  wind,  whilst  permitting 
free  entry  of  air.  The  furniture  should  be  sufficient  for  com- 
fort, without  superfluity.  Carpets  and  curtains  should  be 
easily  removable,  so  as  to  be  shaken  and  dusted  out  of  doors. 
All  sweeping  of  carpets  should  be  strictly  prohibited  in  the 
invalid's  rooms,  and  the  floors  and  furniture  should  be  kept 
free  from  dust  by  the  use  of  cloths  rendered  damp  by  Sanitas 
fluid  or  other  weak  solution  of  a  cleansing  kind.  Washing 
chintz  coverings  to  the  furniture  are  greatly  to  be  commended, 
and  two  or  three  well-chosen  patterns  will  afford  a  change  from 
tim.e  to  time,  grateful  and  cheering"  to  an  invalid  much  con- 
fined to  a  suite  of  rooms.  Every  few  months  rooms  much 
occupied  should  be  thoroughly  cleansed,  the  walls  and  ceilings 
fresh  papered,  or  hme-whited  and  coloured.  If  papered  with 
"Salubra"  paper,  they  should  be  thoroughly  washed  with 
some  disinfectant  solution  such  as  cyllin  (4  ounces  to  a  gallon 
of  water). 

Much  irritation,  cough,  and  increased  activity  of  disease, 
will  be  avoided  by  these  simple  measures,  and  the  more  the 
patient  is  confined  to  his  rooms,  the  more  essential  is  it  that 
strict  attention  should  be  paid  to  them.  In  the  presence  of 
broken  and  highly  absorbent  surfaces  deprived  of  the  means 
of  rejecting'  harmful  matters,  the  mechanical  irritation  of  inert 
dust,  and  the  septic  influence  of  putrefactive  and  other 
organisms,  are  fertile  of  mischief.  Gas-hghting-  should  be 
forbidden  in  the  living--rooms.  The  patient  must  have  a 
separate  bed,  springy,  with  horsehair  mattress,  not  curtained, 
and  sufficiently,  but  not  heavily,  covered.  In  bed-ridden  cases 
it  is  often  a  good  plan  to  have  two  beds  in  occupation,  so  that 
a  change  may  be  made  from  one  to  the  other.  The  clothing 
of  the  patient  should  be  warm  and  light,  and  even  in  the 


600  DISEASES   OF   THE   LUNGS   AND   PLEURA 

warmest  season  thin  woollen  or  silken  garments  should  be 
worn  next  the  skin. 

A  reference  to  the  chapters  on  Etiology  will  emphasise  the 
importance  of  adopting  every  possible  measure  of  cleanliness 
with  reg'ard  to  the  disposal  of  the  expectoration  from  con- 
sumptive patients;  for,  directly  or  indirectly,  this  is  the  great 
source  of  danger.  We  are  in  the  habit  of  advising  for  bed- 
ridden cases  a  bib  kept  moist  by  a  weak  formalin  solution, 
which  serves  as  a  constant  and  salutary  inhalant  and  to  catch 
and  diminish  the  infectivity  of  any  spray  which  may  result 
from  coughing.  As  a  further  precaution,  a  Japanese  handker- 
chief should  be  brought  across  the  mouth  when  expectorating. 
The  employment  of  suitable  spitting"  vessels  is  to  be  insisted 
upon,  and  the  proper  disinfection  of  such  vessels  and  the 
efficient  destruction  of  their  contents  is  equally  important. 

Spittoons  of  various  patterns  may  be  used,  the  essential 
point  being  that  they  contain  a  liquid,  not  a  dry,  disinfectant. 
Sputum  is  only  dangerous  when  dry,  so  that  some  liquid  in 
the  receiver  is  of  the  first  importance,  the  exact  nature  of  the 
liquid  being-  comparatively  immaterial — Sanitas  or  weak  car- 
bolised  solutions  may  be  used;  cyllin  (Jeyes'  fliuid),  i  in  400, 
is  also  effective,  and  not  expensive. 

The  next  point  of  importance  is  the  cleansing  of  these 
vessels  and  the  destruction  of  their  contents.  Destruction  by 
fire  is  one  of  the  best  and  easiest  ways  of  dealing  with  the 
sputum,  which  in  private  cases,  when  the  amount  is  quite 
small,  can  be  simply  poured  on  to  the  fire;  or  a  spitting-cup 
may  be  used,  consisting  of  a  metal  frame,  into  which  fits  a 
stiff  and  water-tight  paper  case  shaped  like  a  spittoon,  capable 
of  holding  a  disinfectant;  this,  after  use,  can  be  lifted  out  of 
the  frame,  burnt,  and  replaced  by  a  fresh  one.  When  larger 
in  amount,  so  that  there  may  be  a  possible  risk  of  the  sputum 
falling  unburnt  through  the  fire  into  the  grate  beneath,  and 
here  becoming  dried  and  a  source  of  danger,  it  is  best  to  pour 
the  sputum,  mixed  with  the  disinfectant,  into  the  water-closet 
and  thus  into  the  drainage  system. 

In  hospitals  and  sanatoria,  where  the  amount  of  sputum  to 
be  dealt  with  is  greater,  special  methods  have  to  be  employed. 
At  the  Brompton  Hospital  a  cremator  was  erected,  and  for 
some  years  the  sputum  was  destroyed  in  this  manner.  The 
method  was  effective,  but  the  cremator  was  found  to  need  such 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  6oi 

constant  repair  that  another  method  had  to  be  devised.  That 
now  in  use  consists  in  subjecting  the  sputum  to  superheated 
steam  (250°  F.)  for  a  period  of  twenty  minutes  in  an  apparatus 
devised  for  the  purpose.  After  sterihsation,  the  steam  is 
turned  off,  and  the  disinfected  sputum  is  allowed  to  cool  down 
nearly  to  100°  F.,  when,  by  opening  a  valve,  it  is  allowed  to 
pass  by  gravity  into  the  drain.  This  apparatus,  devised  by 
Dr.  Paterson,  at  the  time  resident  medical  officer,  and  Mr. 
Kirkland,  consulting  engineer  to  the  hospital,  has  now  been 
in  use  for  some  years,  and  is  found  to  work  simply  and  well.^ 
A  duplicate,  installed  at  the  King  Edward  VII.  Sanatorium, 
Midhurst,  has  given  equally  good  results. 

Glass,  china  or  metal  spitting-  vessels,  when  emptied,  must 
be  scalded  out,  and  cleansed  with  washing-soda  and  water. 
Consumptive  patients,  when  out  of  doors  or  travelling",  should- 
carry  suitable  pocket  flask  spittoons.  The  habit  of  expector- 
ating into  handkerchiefs  should  be  avoided  as  much  as  pos- 
sible, and  handkerchiefs  so  used  should  be  frequently  changed, 
and  at  once  thrown  into  some  convenient  receptacle  contain- 
ing a  disinfecting  fluid,  then  scalded  and  sent  to  the  wash. 
For  bed-ridden  patients  an  abundant  supply  of  small  squares  of 
linen,  butter-muslin  or  Japanese  paper  should  be  at  hand  on  a 
vulcanite  tray  or  glass  slab,  and  should  be  burned  when  used. 
All  these  precautions,  it  must  be  especially  remembered,  are 
sanitary  measures,  to  be  adopted  in  the  interest  of  the  patient 
himself,  who  is  the  most  susceptible  to  unhygienic  surround- 
ings, as  well  as  of  others  in  his  neighbourhood.  With  such 
measures  of  careful  hygienic  cleanliness,  which  can  be  easily 
carried  out  without  fuss  or  ostentation,  any  anxiety  as  to  the 
contagiousness  of  the  disease  may  be  allayed. 

Dietary. — The  dietary  of  the  phthisical  patient  is  a  very  im- 
portant question,  which  we  shall  consider  in  detail  in  a  later 
chapter.  We  may  here,  however,  say  that  it  must  be  framed 
on  a  liberal  scale,  so  as  to  contain  a  due  share  of  animal  and 
vegetable  food  and  salts.  The  appetite  and  digestive  powers 
of  the  patient  are  in  many  cases  sufficient  guides  as  to  the 
amount  of  food  to  be  taken.  The  results  of  Debove's  method 
of  feeding  phthisical  patients  artificially  by  means  of  an 
cesophageal  tube  showed,  however,  many  years  ago,  what 
clinical  observation  also  teaches,  that  appetite  often  fails  when 
the  system  is,  nevertheless,  ready  and  able  to  assimilate  much 


602  DISEASES   OF   THE   LUNGS    AND   PLEUR/5: 

larger  quantities  of  food.  This  fact  is  especially  to  be  recol- 
lected during  the  hectic  period  of  phthisis,  when  it  is  most 
important  to  sustain  the  patient  by  nourishment,  given  in 
much  larger  quantities  than  inclination  would  prompt  him 
to  call  for,  and  yet  without  resorting  to  that  forced  dietary 
which  w^as  formerly  in  vogue,  and  which  is  now  justly  dis- 
credited. 

In  cases  of  quiescent  phthisis  the  natural  appetite  returns, 
and  patients  as  a  rule  take  food  with  avidity.  Sometimes, 
when  flesh  and  blood  are  being  rapidly  regenerated,  and  a  ten- 
dency is  observed  for  the  body-weig'ht  to  pass  beyond  the 
lung  capacity,  it  is  advisable  to  restrict  the  dietary  somewhat, 
by  diminishing  malt  liquors,  substituting  fish  for  butcher's 
meat,  and  suggesting  some  restrictions  in  the  amount  of  fluids 
and  solids  taken.  Coated  tongue,  quickened  pulse  and  respira- 
tion, restlessness,  dyspepsia,  and  increased  breathlessness  on 
effort,  will,  in  the  absence  of  any  fresh  lesion,  lead  to  the  recog- 
nition of  this  condition,  already  referred  to  as  one  of  relative 
plethora. 

The  digestive  system  of  tuberculous  patients  requires  care- 
ful attention,  and  in  m^any  cases  treatment  mainly  consists 
in  establishing  a  working  equilibrium  between  the  digestive 
powders  on  the  one  hand,  and  the  quantity  and  quality  of  food 
taken  on  the  other,  the  aid  of  medicines  being  called  in  to 
support  digestive  powers  and  to  correct  digestive  failure.  A 
fertile  source  of  dyspepsia  is  the  swallowing  of  expectoration, 
and  patients  should  be  carefully  warned  of  this. 

From  time  to  time  certain  special  kinds  of  diet  have  been 
suggested  as  curative  of  phthisis,  such  as  the  milk  cure,  the 
whey  cure,  koumiss  treatment,  the  grape  cure,  and  the  like. 
None  of  these  measures  of  treatment  will,  as  "  cures,"  bear 
examination,  much  of  the  benefit  being-  attributable  to  the 
healthy  surroundings  of  the  "cure,"  and  it  is  now  admitted 
that  such  cures  are  only  adapted  to  a  limited  number  of  favour- 
able cases  of  the  disease.  This  limited  number  of  favourable 
cases  of  phthisis,  it  must,  indeed,  be  confessed,  make  the  repu- 
tation of  every  health  resort  and  "  cure  "  in  turn,  and  attract 
to  them  many  other  cases  for  which  they  are  not  suited. 

The  exclusive  use  of  milk  is  not  adapted  for  the  treatment 
of  any  form  of  consumption,  but  in  all  cases,  and  especially  in 
young  subjects,  milk  to  the  extent  of  from  one  to  two  pints, 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  603 

boiled  or  pasteurised,  may  be  taken  daily  by  those  who  can 
digest  it  until  the  body-weight  is  a  httle  above  the  normal 
height-weight  ratio.  Cow's  milk  (undiluted  or  skimmed), 
ass's  milk,  goat's,  mare's,  or  fermented  mare's  milk  (koumiss), 
may  be  used.  In  some  cases  whey  may  be  preferred;  its  nutri- 
tive value  is  not  large,  but  for  those  who  cannot  take  other 
forms  of  milk  it  may  be  tried,  especially  in  cases  in  which  there 
is  a  considerable  loss  of  salts  in  night  perspirations. 

Koumiss,  the  fermented  milk  of  mares,  has  from  all  time 
been  used  as  a  beverage  by  the  inhabitants  of  the  steppes  of 
Southern  Russia,  the  best  koumiss  being  prepared  from  pas- 
ture-fed mares  which  have  not  been  put  to  work.  Ssamara  is 
the  steppe  district  where  Russian  koumiss  of  the  best  kind  is 
rnade,  and  the  best  quality  is  obtained  in  May,  June  and  July, 
when  the  climate,  clear,  dry,  and  aromatic,  is  said  to  be  very 
beneficial.  A  glass  or  two  is  taken  in  the  early  morning', 
three  or  four  glasses  in  the  forenoon,  and  as  manv  in  the  after- 
noon.  No  other  drink  should  be  taken,  and  no  sweets  or 
alcohol  in  any  other  form,  the  meals  consisting  of  a  liberal 
allowance  of  mutton,  poultry,  eggs,  butter  and  bread.  The 
treatment  must  be  commenced  with  caution,  and  should 
extend  over  a  period  of  two  or  three  months,  as  much  time 
as  possible  being  spent  in  the  open  air,  riding  or  walking. 

We  fear  it  will  be  some  years  before  Russia  can  be  visited 
for  purposes  of  health,  and  the  koumiss  cure  is  not  therefore 
likely  to  attract  at  the  present  time  many  patients  from  this 
country;  nevertheless,  the  beverage  is  one  which  will  be  found 
useful  on  occasions,  certain  patients  retaining  it  when  the 
stomach  will  tolerate  nothing-  else.  True  koumiss  made  from 
mare's  milk  is  difficult  to  obtain  in  London,  but  a  substitute 
prepared  from  cow's  milk  is  supplied  by  various  dairies.  The 
following  formula,  kindly  supplied  to  us  by  the  late  Dr. 
Charles,  of  Cannes,  may  be  found  useful : 

'"  Home-made  Kouiniss. — Fresh  milk  to  be  just  boiled,  then,  when 
nearly  cold,  put  into  champagne  quart  bottles,  leaving  enough  room 
to  shake  it  up  easily;  add  a  teaspoonful  of  crushed  lump  sugar,  and  a 
piece  of  German  yeast*  about  the  size  of  a  hazel-nut — i.e.,  20  grains; 
cork  with  new  corks,  and  tie  down  with  wire  or  string ;  keep  in  a  cool 

*  The  German  yeast  can  be  obtained  from  any  baker  who  makes  Vienna 
or  fancy  bread.  It  soon  putrefies,  and  should  therefore  be  used  fresh  ; 
but  if  placed  in  a  cup  loosely  covered  up  with  paper,  it  will  keep  a  week. 


604  DISEASES   OF   THE  LUNGS    AND   PLEURA 

place,  lying  down,  and  shake  twice  a  day.  The  koumiss  will  be  ready 
to  drink  on  the  sixth  day  in  average  weather,  earlier  in  hot,  and 
later  in  cold,  weather.  A  thinner  koumiss  is  made  from  skimmed 
milk.  This  more  resembles  the  koumiss  made  from  mare's  milk. 
Most  people  can  digest  that  made  from  unskimmed,  and  for  them 
it  is  a  mistake  to  use  skimmed  milk.  All  the  bottles,  corks,  etc.,  must 
be  scrupulously  clean." 

The  Grape  Cure. — This  is  especially  carried  on  at  Meran, 
Botzen,  Montreiix,  and  some  other  resorts  in  Europe,  during 
September  and  October.  Professor  Lebert-  recommended 
half  a  pound  of  grapes  to  be  taken  early  in  the  morning,  at 
7  a.m.,  and  again  at  5  p.m.,  and,  after  a  few  days,  a  third  quan- 
tity at  II  a.m.;  following  this,  if  the  fruit  be  well  borne,  the 
total  quantity  taken  each  day  may  be  gradually  increased  to 
2  pounds,  this  being  the  safe  limit  to  which  this  treatment 
can  be  carried  in  phthisis.  The  diet  at  other  meals  must  be 
Hght,  digestible,  and  unstimulating.  There  is  no  doubt  that 
cases  of  phthisis  are  frequently  not  allowed  sufficient  vegetable 
food  and  salts  in  their  dietary,  and  when  and  where  grapes 
are  in  season  the  substitution  of  them  for  the  intermediate 
meals  may  often  be  of  value,  especially  in  cases  of  hectic  asso- 
ciated with  torpidity  of  the  bowels. 

Exercise. — This  must  be  taken  or  withheld  in  accordance 
with  the  patient's  strength  and  the  activity  and  stage  of  the 
disease.  In  the  active  phases  of  the  malady,  with  elevation  of 
temperature,  quick  pulse,  and  hurried  breathing,  all  symptoms 
will  be  intensified  by  exercise,  and  complete  muscular  rest 
must  be  enjoined,  in  association  with  the  best  air  conditions 
that  can  be  provided.  In  connection  with  the  digestion  of 
food,  rest  is  of  great  importance,  and  in  many  cases  of  phthisis 
we  are  in  the  habit  of  enjoining  as  a  minimum  of  rest  one  hour 
reclining-  after  breakfast,  one  before  and  one  after  luncheon, 
and  a  fourth  from  six  to  seven,  the  patient  "being  about" 
and  taking-  such  exercise  at  other  times  as  may  be  advised. 
By  means  of  revolving-  shelters,  tents,  sheds,  bath-chairs,  mov- 
able beds,'^  and  appropriate  arrangement  of  wraps,  all  the 
advantages  of  open  air  may  be  obtained  without  exercise  in 
suitable  climates  and  seasons ;  and  much  care  in  room  hygiene 
on  the  lines  already  laid  down  will  compensate  for  extra  time 
spent  indoors  in  consequence  of  bad  weather,  or  in  advanced 

*  One  of  Ward's,  Aldermann's,  or  Carter's  mechanical  bed-chairs  is  a 
great  luxury  as  an  addition  to  the  sick-room  furniture. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  605 

cases.  In  early  stages  of  quiescent  cases  an  outdoor  life  is  to  be 
advised,  and  those  occupations  and  climates  selected  in  which 
this  can  be  best  attained.  For  further  details  we  must  refer 
the  reader  to  the  chapters  on  Climatic  Change  and  Sanatorium 
Treatment. 

REFERENCES. 

'  For  a  full  description  of  the  Apparatus  see  "  The  Sterilisation  of 
Tuberculous  Sputum  and  Articles  infected  by  the  Tubercle  Bacillus,"  by 
Thomas  Kirkland,  M.I.C.E.,  and  Marcus  S.  Paterson,  M.B.,  The  Lancet, 
1906,  vol.  ii.,  p.  426. 

^  Quoted  by  Dr.  Burney  Yeo  in  the  chapter  on  "  The  Grape  Cure  "  in 
his  work  on  Climate  and  Health  Resorts,  p.  313.  See  also  Climatotherafy 
and  Balneotherapy,  by  Sir  Hermann  Weber,  M.D.,  and  F.  Parkes  Weber, 
M.D  ,  p.  621.     London,   1907. 


CHAPTER  XLIII 

TREATMENT  OF  PULMONARY   TUBERCULOSIS   IN   ITS   EARLY 

STAGES 


Sanatorium  Treatment. 

Tuberculosis  of  the  kings  may,  as  we  have  indicated,  mani- 
fest itself  as  an  acute  form  of  the  disease,  associated  with  high 
fever,  and  marked  by  rapid  spread  of  the  tuberculous  process. 
This  variety  must  be  treated  by  absolute  rest  in  bed  on  fresh- 
air  lines,  the  strength  being  maintained  by  an  abundant 
dietary,  and  the  special  symptoms  relieved  by  appropriate 
medicines  (Chapter  XLVII.).  vSuch  cases  are,  however,  not 
now  before  us,  and  we  have  in  this  chapter  to  consider  the  lines 
which  should  be  adopted  in  the  more  ordinary  cases  in  which 
the  onset  of  the  disease  is  insidious,  marked,  perhaps,  by 
cough,  wasting,  or  haemoptysis,  in  which  the  process  is  less 
active,  and  fever,  if  present,  is  only  slight  in  degree. 

With  regard  to  such  cases,  the  first  essential  is  to  place  the 
patients  under  the  best  hygienic  conditions  obtainable,  and  to 
secure  for  them  an  abundance  of  the  purest  air.  The  diet 
must  be  ample  and  nutritious,  not  in  great  excess,  but  duly 
proportioned  to  the  body-weight.  As  convalescence  becomes 
established,  gradually  increasing  exercise  should  be  prescribed 
under  careful  observation.  Such  treatment  may  be  carried 
out  in  a  patient's  own  home,  if  it  be  satisfactorily  situated,  and 
cL  carefully-trained  nurse  be  available.  Medical  practitioners 
are  now  becoming  in  increasing  numbers  sufficiently  well 
versed  in  the  management  of  these  cases.  It  is  not  often, 
however,  that  the  home  conditions  are  entirely  satisfactory, 
and  we  have  no  hesitation  in  saying  that  in  the  majority  of 

instances  it  is  best  for  the  patient  to  go  for  a  time  to  a  sana- 

606 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  607 

torium,  where  he  will  receive  the  individual  attention  which 
his  case  requires,  and  where  he  will  be  educated  in  the  life 
which  he  must  live  after  returning  home. 

It  is  not  our  purpose  here  to  describe  in  detail  the  construc- 
tion of  a  sanatorium.  Such  institutions,  foreshadowed  by 
George  Bodington^  in  1840,  and  Henry  McCormac-  in  1855, 
and  brought  into  practical  operation  by  Brehmer  at  Gorbers- 
dorf,  and  Dettweiler  at  Falkenstein,  are  now  to  be  found  in 
greater  or  less  numbers  in  most  civilised  countries.  They  con- 
sist essentially  of  buildings  specially  designed  to  enable  the 
patient,  when  within  doors,  whether  in  a  bedroom,  dining  or 
recreation  room,  to  live  almost  as  it -were  in  the  open  air.  To 
this  end  the  patients'  rooms  are  built  facing  towards  the  south ; 
the  rooms  are  large  and  airy,  and  the  window-space  of  unusual 
size.  A  veranda  in  front,  on  to  which  the  windows  open,  and 
on  which  the  patient  may  lie  out  during  the  rest-hour,  is  an 
advantage.  By  the  construction  of  an  open  corridor  to  the 
north,  into  which  the  doors  of  the  sleeping-room,  and  the  win- 
dows above  them,  open,  a  continual  circulation  of  air  in  the 
room  is  obtained.  To  avoid  undue  dampness,  care  is  taken,  in 
selecting  a  site  for  the  sanatorium,  to  choose  a  dry  subsoil, 
often  in  pine  and  heath-clad  districts,  but  with  the  trees  not 
too  near  the  buildings.  Protection  from  wind  is  usually 
secured  by  rising  ground  to  the  north,  and  often  also  by  belts 
of  trees  to  the  north  and  east,  which,  if  sufficiently  dense,  form 
an  effective  screen.  To  facilitate  cleaning,  and  to  preclude 
the  harbouring  of  infected  dust,  all  corners  in  such  buildings 
should  be  rounded  and  the  furniture  simple,  and  of  such  a 
kind  as  may  be  easily  wiped  over  with  a  damp  cloth.  Carpets 
should  be  avoided,  but  slips  of  rug  may  be  allowed  for 
comfort. 

On  first  being-  received  into  such  an  institution,  the  patient 
should  be  kept  in  bed  for  about  a  week,  so  that  a  careful 
estimate  of  the  activity  of  the  disease  may  be  obtained.  If  the 
temperature  prove  normal,  the  patient  may  then  be  allowed 
up  for  a  short  time  in  the  day,  the  duration  to  be  gradually 
extended,  provided  always  that  the  extra  exertion  does  not 
lead  to  any  febrile  reaction.  Later  on  exercise  ma,y  be  per- 
mitted, beginning,  perhaps,  with  a  quarter  of  a  mile  slowly 
walked  each  day.  If  all  goes  well,  this  is  gradually  increased, 
and  soon  the  patient  is  able  to  enter  into  the  life  of  the  institu- 


6o8  DISEASES   OF   THE   LUNGS    AND   PLEURA 

tion,  in  which  each  hour  is  mapped  out  for  him  under  careful 
supervision.  At  the  King-  Edward  VII.  Sanatorium,  near  Mid- 
hurst,  the  daily  programme,  as  set  forth  in  the  "  Daily  Routine 
•and  Rules  for  Patients,"  is  somewhat  as  follows  : 

7.30  a.m.       Gong  is  sounded.     Patients  take  their  temperatures  and 

get  up.     Baths,  hydrotherapy,  etc. 
8.15     ,,  First  breakfast  gong. 

8.30     ,,  Breakfast  gong. 

9-9.30     ,,  Leisure.     Books  can  be  obtained  from  the  Librarian. 

9.30     ,,  Gong  is  sounded.     All  patients  must  go  direct  to  their 

rooms,  or  to  that  part  of  the  balcony  immediately 
outside  their  rooms,  and  rest  on  their  chairs  until  they 
have  been  seen  by  their  medical  oiEcers. 
10-12  noon.  Rest  or  exercise  as  prescribed.  On  one  day  in  each 
week  patients  will  attend  in  the  consulting-room  at 
this  hour  for  examination. 
12     ,,  Gong  is  sounded.     All  patients  must  go  direct  to  their 

rooms. 
12-1  p.m.       All    patients    must    rest    in    their    rooms    or    on    their 
balconies.     No  talking  is  allowed. 
1     ,,  First  luncheon  gong. 

1.15     ,,  Luncheon  gong. 

2-2.30     ,,  Leisure. 

2.30-4  30     ,,  Rest  or  exercise  as  prescribed. 

4.30     ,,  Tea  in  entrance-hall. 

[5-6     ,,  Recreation  hour  for  music,  games,  etc. 

6  ,,  Gong  is  sounded.     All  patients  must  go  to  their  rooms 

as  at  twelve  o'clock. 
6-7     ,,  Rest  hour. 

7  ,,  First  dinner  gong. 
7.15     ,,  Dinner  gong. 

8-9.30     ,,  Recreation. 

9.30     ,,  All  patients  must  go  to  their  rooms. 

10     ,,  All  lights  out. 

With  reference  to  the  above,  we  would  insist  that  the  hours 
of  "  leisure  "  and  "  recreation  "  are  not  to  be  spent  in  violent 
amusements,  which  may  be  as  tiring  as  any  exercises  pre- 
scribed. During  these  hours  the  patient's  time  is  more  his 
own.  He  is  allowed  to  amuse  himself,  play  chess,  draughts, 
dominoes,  and  so  forth,  or  at  certain  times  such  simple  games 
as  putting,  clock-golf,  or  bowls.  Music  and  singing  are 
allowed  under  careful  supervision,  for  it  must  be  remembered 
that  both  entail  muscular  exertion,  which,  if  carried  too  far, 
may  do  harm. 

With  regard  to  the  body  temperature,  which  patients  are 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  609 

rightly  taught  at  sanatoria  to  take  themselves,  we  may  here 
remark  that  much  discussion  has  been  evoked  as  to  the  relative 
merits  of  mouth  and  rectal  temperatures.  The  superiority  of 
the  latter  has  been  warmly  upheld  by  Dr.  Otto  Walther  of 
Nordrach  and  his  followers,  and  the  rectal  method  is  now  in 
use  at  many  sanatoria.  There  can  be  little  doubt  that  the 
temperature  so  registered  does  more  nearly  represent  the 
temperature  of  the  body  than  that  taken  in  the  mouth,  groin 
or  axilla.  Further,  it  is  not  subject  to  certain  fallacies,  such 
as  the  cooling  of  the  mouth  by  talking,  great  external  cold,  or 
by  a  cool  wind  blowing  upon  the  cheeks,  by  all  of  which  the 
mouth  temperature  may  be  affected.  Theoretically,  there- 
fore, the  rectal  method  may  be  defended.  It  is,  however, 
naturally  repugnant  to  many  patients  of  refinement,  and  in 
practice  we  believe  that  it  is  unnecessary,  since  any  abnormal 
rise  of  temperature,  to  99°  or  higher,  is  accompanied  by  sub- 
jective symptoms  such  as  headache,  loss  of  appetite,  and  other 
feelings  of  malaise.  Under  such  circumstances  the  patient,  if 
properly  instructed,  will  take  his  temperature  without  delay 
and  with  especial  care,  and  thus  insure  a  correct  mouth-read- 
ing. Working  on  these  Hues,  satisfactory  results  have  been 
obtained  at  the  Brompton  Hospital  Sanatorium  at  Frimley, 
and  we  think  that  they  go  far  to  prove  the  adequacy  of  mouth 
temperatures. 

Exercise  and  Work.— In  the  early  years  of  the  treatment,  in 
accordance  with  the  practice  at  Nordrach,  walking  was  the 
only  serious  exercise  permitted  at  most  sanatoria.  It  was 
thought  that  in  this  way  the  needful  exercise  was  supplied  with 
less  strain  upon  the  chest  and  lungs  than  would  be  the  case 
with  muscular  exercises  involving  the  arms  and  their  attach- 
ments to  the  chest  wall.  At  Nordrach  walking  was  extended 
in  suitable  cases  to  some  sixteen  miles  or  more  a  day,  and, 
with  the  hilly  surroundings  and  the  graduated  walks  thus 
obtained,  the  results  were  very  satisfactory.  Walking  is,  how- 
ever, apt  to  become  monotonous,  unless  great  variety  of 
country  is  at  hand ;  and  experience  has  now  shown  that  other 
forms  of  muscular  exercise  may  be  employed  instead,  without 
danger  to  the  patient,  and  in  many  cases,  indeed,  to  his  immense 
benefit,  both  moral  and  physical. 

At   the    Brompton    Hospital   Sanatorium    at    Frimley    for 
patients   of  the   poorer  classes,    Dr.    Marcus   Paterson,   the 

39 


6lO  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

Medical  Superintendent,  devoted  great  attention  to  this  sub- 
ject, and  devised  and,  with  the  approval  of  the  Visiting  Staff, 
put  into  practice  a  system  of  graduated  labour,  suited  to  the 
needs  of  the  various  patients.  The  labour  is  commenced  as 
soon  as  it  is  seen  that  a  patient  can  walk  six  miles  a  day  with- 
out ill  effects.  The  grades  of  work  and  exercise  may  be  sum- 
marised as  follows  : 

(i)  Walking  from  half  a  mile  to  six  miles  daily;  (2)  carry- 
ing baskets  of  mould  or  other  material,  picking  up  wood, 
watering  plants,  etc.;  (3)  using  a  small  shovel,  cutting  grass 
borders,  hoeing,  etc.;  (4)  using  a  large  shovel,  digging  broken 
ground,  mowing  grass,  etc.;  (5)  using  a  pickaxe,  trenching, 
mixing  concrete,  felHng  trees,  etc.;  and  (6)  similar  work  to 
that  prescribed  in  Grade  5,  but  for  six  hours  daily  instead  of 
four  as  in  the  case  of  the  preceding  grades.  In  addition  to  the 
tasks  thus  allotted  to  them,  the  patients  make  their  own  beds, 
change  their  bed-linen,  clean  their  wards  and  windows,  polish 
the  corridors,  keep  the  dining-halls  clean  and  the  brass-work 
bright,  and  wash  their  plates,  knives  and  forks  after  meals.^ 

The  following  account  gives,  in  Dr.  Paterson's  words,"*  a 
more  exact  description  of  the  amount  of  work  done  in  certain 
of  the  grades : 

"  Grade  2. — Basket-work  is  subdivided  into  three  sections. 
In  the  first  the  patient  carries  a  load  of  about  12  pounds  in 
weight  a  distance  of  50  yards  up  a  gradient  of  i  in  lo-y — i.e., 
rising  14  feet  in  that  distance.  Such  patients  carry  in  a  day 
eighty  loads,  or,  in  other  words,  they  will  carry  8|-  hundred- 
weight a  distance  of  50  yards.  ...  In  the  second  section  the 
weight  carried  is  about  18  pounds,  the  conditions  being  the 
same,  and  these  patients  carry  about  13  hundredweight  per 
day.  In  the  third  section  the  weight  carried  is  24  pounds.  A 
patient  on  this  work  carries  during  the  day  about  iy\  hundred- 
weig"ht  for  the  same  distance. 

"  Grade  3. — The  small  shovel  is  the  ordinary  coal  scoop  pro- 
vided with  a  long  handle.  Patients  commencing  on  this  grade 
of  labour  will  dig  2  tons  of  earth  a  day,  and  raise  it  7  feet  into 
a  cart,  and  as  they  increase  in  strength  will  in  a  day  Hft  about 
4  tons  the  same  height. 

"  Grade  4. — The  large  shovel  is  the  ordinary  shovel  used  by 
a  navvy.  Patients  on  this  grade  will  dig  and  lift  about  6  tons 
a  day  a  distance  of  7  feet. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  6ll 

"  Grade  5. — Pickaxe-work  is  the  hardest  work  possible,  and 
consists  of  breaking  unbroken  ground,  excavating,  etc.  Con- 
crete-mixing comes  under  the  heading  of  pickaxe-work,  as, 
although  the  large  shovel  is  used,  the  work  is  heavier  than 
moving  sand  or  mould. 

"  When  a  patient  has  been  on  a  grade  of  labour  for  about 
three  weeks,  his  fitness  for  harder  work  is  considered.  If  the 
temperature  has  been  normal,  the  weight  satisfactory,  the 
appetite  g"ood,  and  if  he  is  feeling  well  (this  to  be  determined 
by  watching-  the  way  in  which  he  performs  his  work),  then  he 
is  put  on  harder  work." 

On  these  lines,  the  patients  have  carried  out  much  useful 
work  at  the  sanatorium,  although  many  of  them  had  before 
been  engaged  in  clerical  and  sedentary  occupations  and  had 
not  been  accustomed  to  manual  labour.  A  reservoir  capable 
of  holding  500,000  gallons  has  been  excavated  and  concreted. 
Trees  have  been  cut  down  and  sawn  into  firewood,  the  sana- 
torium has  been  painted,  a  kitchen-garden  trenched  and  cul- 
tivated, and  the  grounds  kept  in  order,  each  class  of  work 
being  correlated  to  a  certain  grade  of  labour  in  accordance 
with  the  extent  of  muscular  effort  involved. 

The  results  of  this  method  of  treatment  have  been  gratify- 
ing. A  large  proportion  of  the  patients,  many  of  them  the 
subjects  of  extensive  but  quiescent  pulmonary  disease,  have 
been  able  to  pass  through  all  the  grades  of  labour,  and  to  do 
six  hours  of  the  hardest  navvy  work  daily  before  leaving, 
during  the  last  three  weeks  foregoing  the  hour's  rest  before 
dinner  and  supper,  so  that  on  returning  home  they  are  in  a 
position  to  recommence  work  at  once.  As  the  labour  is 
increased  the  patient's  general  condition  improves,  his  cough 
and  sputum  diminish,  and  may  eventually  disappear.  Espe- 
cially we  would  emphasise  the  fact  that  in  our  experience  the 
method,  under  the  supervision  of  a  careful  Medical  Super- 
intendent, is  free  from  risk.  Haemoptysis,  contrary  to  what 
might  have  been  expected,  is  not  common,  and  from  our  ex- 
perience at  the  Daneswood  Sanatorium,  we  are  inclined  to 
think  that  it  is  less  frequent  than  before  the  introduction  of 
this  form  of  treatment,  which  is  also  in  use,  though  in  a  some- 
what modified  form,  at  this  institution. 

It  sometimes  happens,  indeed,  that  a  patient,  when  moved  to 
a  given  grade,  may  find  the  work  at  first  too  much,  or  in  his 


6l2  DISEASES   OF  THE  LUNGS    AND   PLEURA 

eagerness  to  get  well,  may  do  more  than  he  ought.  Such 
conditions  reveal  themselves  by  headache  and  by  a  slight  rise 
of  temperature  (a  mouth  temperature  of  99-0°  in  men  or  996° 
in  women  is  regarded  by  Dr.  Paterson  as  the  "  danger  signal "), 
and  if  not  checked  would  no  doubt  lead  to  extension  of  the  lung 
disease.  If  the  patient,  however,  is  put  to  bed  at  once,  kept 
at  "  absolute  "  rest,  and  treated  in  this  respect  as  completely 
as  if  he  were  suffering  from  typhoid  fever,  after  three  or  four 
days  the  temperature  will  again  reach  normal,  and  after  the 
lapse  of  a  few  more  days  he  may  be  able  to  return  without  ill 
effect  to  that  grade  of  labour  which  before  proved  excessive. 
Such  events  emphasise  the  importance  of  the  graduation  of 
the  labour  and  of  the  constant  supervision  of  a  skilled  medical 
officer.  In  other  and  less  successful  cases  it  may  not  be  pos- 
sible, even  after  several  attempts,  for  the  patient  to  proceed 
beyond  a  certain  low  grade  of  labour. 

In  addition  to  the  medical  value  of  the  treatment,  we  should 
like  to  bear  testimony  also  to  its  immense  moral  effect  upon 
the  patients.  The  earlier  sanatorium  regime,  especially  when 
much  rest  and  little  exercise  was  practised,  was  not  calculated, 
it  must  be  admitted,  to  make  them  anxious  to  return  to  work, 
even  though  physically  fit  when  discharged  from  the  institu- 
tion. Discontent  in  the  sanatorium  itself,  owing  to  lack  of 
occupation,  was  also  by  no  means  infrequent.  Under  a  system 
of  graduated  labour,  when  its  object  has  been  fully  explained, 
all  is  chang-ed.  The  patients  become  cheerful,  and  take  an 
interest  in  the  scheme,  which  is  at  once  economically  produc- 
tive and  an  agent  in  their  recovery,  and  when  they  leave  the 
sanatorium  they  are  willing  and  in  many  cases  able  to  recom- 
mence work  at  once.  For  these  reasons  the  method  has  now 
been  generally  adopted  in  this  country  in  sanatoria  for  the 
working  classes,  and  with  some  modifications  has  also  been 
introduced  into  certain  private  sanatoria. 

We  may  now  consider  how  the  good  effects  resulting  from 
a  scheme  of  graduated  labour  are  produced.  It  might  be 
imagined  that  the  result  was  simply  due  to  the  better  general 
nutrition  of  the  patient  following  upon  a  proper  and  due 
degree  of  exercise.  This  no  doubt  plays  its  part,  but  the 
observations  of  Dr.  Inman,  the  Superintendent  of  the  Labora- 
tories of  the  Brompton  Hospital,  indicate  that  this  is  by  no 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  613 

means  all,  and  that  we  are  really  dealing  with  a  carefully 
graded  auto-inoculation  of  tubercuHn  in  gradually  increasing 
doses,  and  with,  in  favourable  cases,  an  immunising  response 
on  the  part  of  the  patient.  Dr.  Inman  made  numerous  ex- 
aminations of  the  blood  in  the  cases  under  treatment,  and  he 
has  shown  that  while  early  cases  of  tuberculosis  with  signs  of 
activity  exhibit  marked  variations  in  the  opsonic  index  as  the 
result  of  exercise  (see  p.  585),  similar  to  those  produced  by  a 
dose  of  tuberculin,  those  who  had  passed  through  the  highest 
grade  of  work,  and  had  lost  cough  and  sputum,  and  whose 
disease  was  clinically  arrested,  showed  no  such  sensitiveness 
of  the  index,  but  yielded  an  opsonic  chart  exactly  resembhng 
that  of  ordinary  healthy  individuals.  He  was  able  also  in 
certain  individual  cases  to  trace  this  change  in  the  index  from 
abnormal  to  normal  by  examining  the  blood  at  different  stages 
of  the  treatment,  the  index  becoming  normal  when  the  disease 
is  arrested,  and  when  exercise  no  longer  leads,  as  he  beHeves, 
to  absorption  of  tuberculin.  His  observations  are  of  great 
interest,  and  support  his  contention  that  we  are  really  dealing 
with  auto-inoculation  of  tuberculin,  and  subsequent  immunisa- 
tion. This  view  is,  moreover,  sustained  by  the  fact  that,  as  he 
has  demonstrated,  exertion  in  these  cases  produces  a  response 
to  the  tuberculous  opsonic  index  only,  that  relating  to  the 
staphylococcus  showing  no  variation. 

Diet. — We  may  now  pass  to  the  question  of  the  diet  which 
should  be  given  in  cases  of  phthisis  suitable  for  sanatorium 
treatment.  Not  so  very  long  ago  it  was  the  fashion,  especially 
in  certain  German  sanatoria,  greatly  to  overfeed  such  patients, 
and  at  Grabowsee'^  the  calorie  value  of  the  proteids,  fats,  and 
carbohydrates  in  the  diet  amounted  to  1,200,  2,200,  and  2,100 
respectively,  giving  a  total  calorie  value  of  5,500.  At  Falken- 
stein^,  on  the  contrary,  the  similar  figures  were  530,  1,120,  and 
1,050,  with  a  total  value  of  2,700. 

Overfeeding  is  in  contravention  of  a  principle  already  laid 
down ;  that  the  body-weight  and  blood-volume  cannot  for  long 
transgress  the  respiratory  capacity  without  a  corrective  dis- 
turbance often  difficult  to  control.  Some  few  years  ago  Dr. 
Bardswell  and  Dr.  Chapman,  in  conjunction  with  Professor 
Goodbody,^  made  some  important  observations  at  the  Bromp- 
ton  Hospital  upon  metabolism  in  phthisis,  and  especially  in 


6i4 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


connection  with  the  overfeeding  which  the  disciples  of  Dr. 
Walther  of  Nordrach  were  at  the  time  zealously  upholding. 
Their  results  showed  that  "  very  large  diets  gave  unsatisfac- 
tory results,  as,  although  weight  was  gained,  it  was  only  at  the 
expense  of  the  general  health,  indicated  by  failure  of  appetite, 
more  marked  digestive  disturbances,  increased  intestinal 
putrefaction,  and  in  one  case  vomiting."  Further,  "this  gain 
of  body-weight  was  not  associated  with  any  more  satisfactory 
progress  in  the  tubercular  lesion  than  was  obtained  with  the 
smaller  diets''^ — an  opinion  which  will  be  fully  confirmed  by 
physicians  who  have  examined  patients  returned  from  sana- 
toria at  which  the  system  was  practised,  perhaps  two  stone 
above  weight,  but  so  breathless  as  to  be  scarcely  able  to  cross 
the  room.  As  a  result  of  such  observations,  excessive  over- 
feeding has  now  been  largely  given  up. 

In  choosing  a  diet  for  a  sanatorium  patient,  who  is,  as  a  rule, 
somewhat  below  weight,  we  shall  not  go  far  wrong  if,  as 
recommended  by  Dr.  Bardswell  and  Dr.  Chapman,  who  have 
devoted  considerable  attention  to  the  subject,  we  choose  a 
diet  suitable  for  an  average  person  in  good  health,  but  increase 
the  proteids  therein  by  30  per  cent.,  and  the  total  energy-value 
by  a  similar  amount.  The  extra  calories  required  over  and 
above  that  supplied  by  the  increased  proteid  may  be  made  up 
by  the  addition  of  either  carbohydrates  or  fats — preferably, 
perhaps,  the  latter,  when  we  remember  how  easily  even  very 
large  quantities  of  fat  are  absorbed  by  phthisical  patients.  On 
these  lines  the  diets  at  the  King  Edward  VIL  Sanatorium 
were  constructed  by  Dr.  Bardswell,  then  Medical  Superin- 
tendent, and  the  results  obtained  have  proved  very  satis- 
factory. The  diets  possess  approximately  the  following 
nutritive  values : 


Proteids 
(in  grammes). 

Fats 
(in  grammes). 

Carbo- 
hydrates 
(in  grammes). 

Calories. 

Men         

Women 

144 
126 

160 
160 

270 
220 

3,186 
2,814 

In  detail  the  diets  are  as  follows 


TREATMENT   OF   PULMONARY   TUBERCULOSIS 


615 


STANDARD  DIETS  IN  USE  AT  THE  KING  EDWARD  VII. 

SANATORIUM. 


Men. 

Women. 

Time. 

Diet. 

Quantity. 

Diet. 

Quantity. 

7.30  a.m. 

Milk            

\  pint 

Milk              

2  pint. 

8.30  a.m. 

Breakfast. 

Breakfast. 

Porridge  (with  milk) 

i  pint 

Porridge  (with  milk) 

1  pint. 

Egg             

I  (4  days 

Egg              

I  (4  days 

a  week) 

a  week). 

Meat  (A),  etc. 

2  oz. 

Meat  (A),  etc. 

i^  oz. 

Bread          

2  oz. 

Bread          

ih  oz. 

Butter         

\  oz. 

Butter         

i"oz. 

Tea,    coffee,     mar- 

Tea,    coffee,     mar- 

malade, etc. 

q.s. 

malade,  jam,  etc. 

q.s. 

1.T5  p.m. 

Luncheon. 

Luncheon. 

Meat  (B)    

3  oz. 

Meat(B)     

2\  OZ. 

Pudding    (suet    or 

Pudding     (suet     or 

milk)       

5  oz. 

milk)       

3  oz. 

Bread         

2  oz. 

Bread         

i^  oz. 

Butter         

h  oz. 

Butter         

\  oz. 

Potatoes  and  vege- 

Potatoes and  vege- 

tables, or  salad 

q.s. 

tables,  or  salad 

q.s. 

Stewed  fruit,   jam, 

Stewed   fruit,   jam, 

etc 

q.s. 

etc.          

q.s. 

Cheese  and  biscuits 

q.s. 

Cheese  and  biscuits 

q.s. 

4.30  p.m. 

Tea  (optional). 

Tea,  bread  and  but- 
ter,   sandwiches, 

Tea  (optional). 

Tea,  bread  and  but- 
ter,   sandwiches, 

or  cake 

q.s. 

or  cake 

q.s. 

7-15  p.m. 

Dinner. 

Soup    or   fish    (op- 
tional)      

Dinner. 

Soup    or    fish    (op- 
tional)      

Meat  (C)     

3  oz. 

Meat(C)    

2\  oz. 

Pudding    (milk     or 

Pudding    (milk    or 

suet)        

5  oz. 

suet) 

3  oz. 

Bread         

2  oz. 

Bread         

I2  oz. 

Butter        

h.  oz. 

Butter        

i  oz. 

Milk            

ipint 

Milk            

1  pint. 

Potatoes  and  vege- 

Potatoes and  vege- 

tables       

q.s. 

tables      

q.s. 

Stewed    fruit,   jam. 

Stewed   fruit,   jam, 

etc.          

q.s. 

etc.          

q.s. 

Cheese  and  biscuits 

q.s. 

Cheese  and  biscuits 

q.s. 

9.30  p.m. 

Milk            

2  pint 

Milk            

I  pint. 

6l6  DISEASES   OF  THE  LUNGS   AND   PLEURA 

N.B. — The  weights  given  are  the  minimum  quantities  which  are  pre- 
scribed ;  second  helpings  of  meat,  pudding,  and  butter  are  allowed,  if 
asked  for.  We  may  add  that  during  and  since  the  war  margarine  has  been 
substituted  for  butter. 

Meat  (A).  At  breakfast,  on  different  days  of  the  week,  one  of  the  follow- 
ing is  provided  : 

Bacon,  ham,  fish,  tongue,  or  sausage. 

Meat  (B).     At  lunch  this  consists  of  one  of  the  following  : 

Roast  or  boiled  beef,  hot  or  cold. 

Roast  or  boiled  mutton,  hot  or  cold. 

Beefsteak  and  kidney  pudding,  stewed  steak  or  Irish  stew,  or  liver  and 
bacon. 

Chicken,  roast  lamb,  veal,  or  pork  occasionally. 

Meat  (C).     At  dinner  this  consists  of  one  of  the  following  : 

Hot  roast  or  boiled  beef,  hot  roast  or  boiled  mutton,  hot  roast  lamb. 

When  the  sanatorium  was  first  opened  in  1906  a  further 
half-pint  of  milk  was  given  with  luncheon,  but  after  some 
experience  this  was  discontinued,  it  being  found  that  patients 
taking  this  quantity  of  milk  tended  to  become  too  fat.  The 
proper  calorie  value  of  the  diet  was  maintained  by  increasing 
the  helping  of  porridge  at  breakfast  and  the  suet  intake,  and 
by  the  addition  of  extra  vegetable  proteid  in  the  form  of  peas, 
beans,  or  lentils.  On  the  dietary  so  modified  it  is  found  that 
patients  below  their  normal  weight  usually  gain  about  i^-  to 
2  pounds  a  week.  When  some  6  pounds  above  their  average 
normal  weight,  the  diet  is  somewhat  diminished,  the  amount 
of  milk  being  still  further  reduced. 

For  the  industrial  classes,  accustomed  to  fewer  but  larger 
meals,  it  is  found  at  the  Brompton  Hospital  Sanatorium  that 
it  is  better  to  give  the  requisite  nourishment  in  three  solid 
meals — breakfast  (8.15  a.m.),  dinner  (i  p.m.),  and  supper 
(6.30  p.m.),  with  a  cup  of  tea  at  4.30— rather  than  in  smaller 
quantities  at  more  frequent  intervals. 

Should  the  temperature  rise  during  the  treatment,  and  the 
patient  be  confined  to  bed,  the  diet  need  not  necessarily  be 
altered;  but  if  the  appetite  fail,  it  may  be  tempted  by  varying 
the  food.  Thus,  fish,  chicken,  sweetbread  or  mince  may  be 
ordered  instead  of  the  more  sohd  joints,  whilst  the  milk  and 
suet  puddings  are  replaced  by  junkets,  custards,  and  jellies. 

Alcohol  is  but  rarely  required  by  patients  undergoing  sana- 
torium treatment,  but  should  the  appetite  flag,  or  the  case 
"hang  fire,"  a  glass  of  Burgundy,  port  wine,  or  good  beer  at 
lunch  and  dinner  may  sometimes  be  prescribed  with  advantage. 
It  is  in  these  cases  that  the  rest-hour  preceding  lunch  and 


TREATMENT   OF   PULMONARY  TUBERCULOSIS  617 

dinner  becomes  of  especial  value,  and  it  is  a  good  rule  with 
such  patients  to  insist  on  its  continued  observance  for  some 
considerable  time  after  returning-  home. 

Medicinal  Treatment. — The  Dispensary  at  a  sanatorium  does 
not  usually  play  a  very  important  role.  The  early  cases  with 
but  little  active  disease,  which  are  best  suited  for  the  treat- 
ment, improve,  as  a  rule,  rapidly  without  medicine,  though 
from  time  to  time  a  mixture  for  dyspepsia,  or  more  commonly 
a  simple  laxative,  may  be  required.  In  the  smaller  percentage 
of  active  cases,  which  are  to  be  found  in  all  such  institutions, 
drugs  are  of  greater  value,  and  their  administration  will  be 
considered  in  a  later  chapter  (p.  671).  The  question  of  com- 
bining tuberculin  with  sanatorium  treatment  will  also  be 
discussed  (p.  711). 

After  a  stay  at  a  sanatorium  for  a  certain  time  there  are 
many  people  who  may  with  advantage  continue  to  live  a 
country  life,  pursuing  similar,  but  less  rigid,  lines  of  treat- 
ment. For  such  mitigated  and,  so  to  say,  "peripatetic"  cases 
of  phthisis,  which  are  often  to  be  found  at  health  resorts,  it  is 
our  custom  to  lay  down  some  such  rules  as  the  following : 

They  should  take  one  hour's  rest  after  breakfast,  one  before 
and  one  after  lunch,  and  one  before  dinner.  Their  diet  should 
be  generous,  and,  if  necessary,  before  the  morning  walk  we 
would  prescribe  an  ounce  or  two  of  raw-meat  juice.*  The 
afternoon  tea  may  be  directed  to  be  made  with  milk  instead  of 
water,  and  at  night,  and  perhaps  also  in  the  early  morning, 
some  malted  milk  food,  such  as  Horlick's  or  MelHn's,  may 
often  be  taken  with  advantage.  Due  exercise,  regulated  by 
the  patient's  strength,  must  be  taken,  and  the  open-air  plan  of 
treatment  continued.  On  lines  such  as  these  consumptives 
belonging  to  the  upper  classes  not  uncommonly  maintain  their 
health,  even  though  the  pulmonary  disease  may  be  advanced. 

REFERENCES. 

^  An  Essay  on  the  Treatment  and  Cure  of  Pulmonary  Consumftion,  by 
George  Bodington,  surgeon.  London,  1840.  Reprinted  by  the  New 
Sydenham  Society,  1901,  vol.  clxxiii. 

*  This  may  be  best  prepared  by  squeezing  the  juice  from  half  a  pound  of 
mutton  or  beef  previously  just  browned  at  the  fire  to  give  the  taste  of 
cooking  ;  it  may  then  be  served  in  a  coloured  claret  glass,  with  one  or  two 
teaspoonfuls  of  port  wine  to  flavour,  and  taken  with  a  biscuit  or  finger  of 
sponge  cake. 


6l8  DISEASES   OF   THE  LUNGS   AND   PLEUR.E 

^  On  the  Nature,  Treatment,  ayid  Preve7ition  of  Pulmonary  Consumption, 
and  incidentally  of  Scrofula,  with  a  Demonstration  of  the  Cause  of  the 
Disease,  by  Henry  McCormac,  M.D.     London,  1855. 

^  The  description  is  taken  from — 

(i)  The  Sixty-eighth  Annual  Report  of  the  Hospital  for  Consumption, 
Brompton,  1909,  p.  ix. 

(2)  "  Graduated  Labour  in  Pulmonary  Tuberculosis,"  by  M.  S.  Pater- 
son,  M.B.,  Transactions  of  the  Sixth  International  Congress  on 
Tuberculosis  [Washington).  Philadelphia,  1908,  vol.  i.,  part  ii., 
p.  886. 

*  "  Graduated  Labour  in  Pulmonar}'  Tuberculosis,"  by  M.  S.  Paterson, 
M.B.,  Transactions  of  the  Sixth  International  Congress  on  Tuberculosis 
[Washington).     Philadelphia,  1908,  vol.  i.,  part  ii.,  p.  890. 

^  "  Diet  in  Tuberculosis,"  by  Professor  Irving  Fisher,  New  Haven, 
Conn.,  Transactions  of  the  Sixth  International  Congress  on  Tuberculosis 
[Washington).     Philadelphia,  1908,  vol.  i.,  part  ii.,  p.  694. 

■^  "  On  Metabolism  in  Phthisis,"  by  Francis  W.  Goodbody,  Noel  D. 
Bardswell,  M.D.,  and  J.  E.  Chapman,  L.R.C.P.,  Transactions  of  the  Royal 
Medical  and  Chirurgical  Society,  1901,  vol.  Ixxxiv.,  p.  35. 

'  Diets  in  Tuberculosis,  by  Noel  Dean  Bardswell,  M.D.,  and  John  Ellis 
Chapm^an,  M.R.C.S.,  L.R.C.P.,  p.  37.     London,  1908. 

*  (i)  Diets  in  Tuberculosis,  by  Noel  Dean  Bardswell,   M.D.,   and  John 

Ellis  Chapman,  M.R.C.S.,  L.R.C.P.,  p.  59.     London,  1908.     See  also 
(2)  First  Annual  Report  of  the  King  Edward   VII.  Sanatorium,  1906- 
1907. 


CHAPTER  XLIV 

TREATMENT  OF   PULMONARY  TUBERCULOSIS   IN   ITS   EARLY 

ST  AO'ES— [Continued) 


Results  of  Sanatorium  Treatment. 

We  have  sketched  in  broad  outline  the  sahent  points  in  sana- 
torium treatment,  and  we  have  pointed  out  that  for  the  great 
bulk  of  the  population  this  treatment  cannot  be  efficiently 
carried  out  except  in  sanatoria,  at  all  events  for  the  first  few 
months;  after  which  time  the  experience  gained  in  personal 
management  may  enable  patients  of  suflicient  self-control  and 
resources  to  continue  the  treatment  at  their  own  homes  or  in 
other  convenient  places.  We  cannot  too  strongly  emphasise 
the  educational  value  of  sanatoria  in  inculcating  hygienic 
methods  of  life,  not  only  upon  the  patient  himself,  but  upon  all 
with  whom  he  is  brought  in  contact. 

Let  us  now  ask  what  are  the  results  which  have  been 
obtained  by  this  means,  and  how  far  it  may  be  regarded  as  an 
advance  on  methods  previously  in  vogue;  and  first  of  all  let 
us  consider  the  question  in  its  relation  to  the  industrial  classes, 
in  whom  the  conditions  of  life  after  leaving  the  sanatorium 
are  often  far  from  satisfactory. 

Results  of  Sanatorium  Treatment  Among  the  Industrial 
Classes. — That  treatment  in  a  sanatorium  is  not,  as  was 
at  first  believed  by  some,  a  panacea  for  all  forms  of 
pulmonary  tuberculosis,  and  in  whatever  stage  of  the  disease, 
is  now  generally  admitted.  The  experience  of  all  who  have 
to  do  with  sanatoria,  as  well  as  the  statistics  from  numerous 
institutions  brought  forward  by  Dr.  Bulstrode'  in  his 
report  upon  this  subject,  unite  in  proving  that  it  is 
only  in  the  early  cases  that  the  most  hopeful  results 
can   be    expected.      Advanced   cases    may   derive    temporary 

6ig 


620  DISEASES   OF   THE  LUNGS   AND   PLEURA 

benefit,  and  leave  with  gain  in  weight,  and  not  a  few 
with  temporary  restoration  of  working  power.  But  after  a 
few  months,  or  it  may  be  a  year  or  two,  the  majority  again 
break  down,  and  succumb  to  their  disease.  This  was  well 
shown  by  Dr.  John  Gray  in  his  "  Summary  of  Results  of  the 
First  Eight  Years'  Working  of  the  Stanhope  Sanatorium, 
Weardale,  Durham"- — an  institution  opened  in  1900  for  the 
treatment  of  consumptive  patients  belonging  to  the  industrial 
classes.  He  gives  a  table  showing  that,  of  317  patients 
admitted  during  the  years  1900-1908  with  advanced  disease 
(Stage  III.,  Turban),  not  more  than  130  were  enabled  to  return 
to  work  after  leaving  the  institution,  and  these,  in  most  cases, 
followed  it  for  a  few  months  only.  Within  four  years  the 
bulk  of  the  patients  were  dead.  Occasionally  such  patients 
live  longer,  and  may  even  surprise  the  physician  by  their 
vitality;  but  such  an  event  is  not  of  frequent  occurrence. 

In  another  table  Dr.  Gray  shows  that,  of  267  patients  admitted 
to  the  same  sanatorium  with  early  pulmonary  tuberculosis 
(Stage  I.,  Turban)  during  the  same  period,  239  were  enabled 
to  return  to  work  after  their  discharge,  and  that  in  1908  only 
46  of  the  267  patients  admitted  during  the  preceding  eight 
years  were  known  to  be  dead,  136,  or  rather  more  than  50 
per  cent.,  being  still  at  work. 

These  conclusions  have  been  universally  confirmed,  and  it 
is  in  fact  obvious  that  advanced  cases  of  phthisis  have  already 
run  their  course  half-way,  or  it  may  be  two-thirds,  towards 
the  end  before  they  come  under  the  sanatorium  regime,  and 
that  the  fullest  advantage  of  this  regime  can  only  be  looked 
for  in  those  who  are  admitted  to  treatment  at  the  earliest 
period.  Every  effort  must  accordingly  be  made  to  persuade 
those  suffering  from  phthisis  to  apply  for  treatment  when  still 
in  the  early  stage  of  their  disease,  since  the  best  results, 
whether  immediate  or  enduring,  are  thus  most  likely  to  be 
secured. 

We  have  dealt  with  this  question  in  much  greater  detail  in 
our  last  edition,  and  may  here  briefly  say  that  the  general 
result  of  treatment  in  industrial  sanatoria  is  that  from  50  to  60 
per  cent,  of  the  cases  taken  in  the  early  stage  are  capable  of 
working  from  four  to  five  years  after  leaving  the  sanatorium 
(see  references  ^  *,  ^  and  ^),  the  margin  of  difference  chiefly 
depending  upon  the  conditions  of  life  to  which  they  return. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  62 1 

On  the  other  hand,  most  of  the  advanced  cases  would  be  dead 
within  four  years.^ 

The  Importance  of  Efficient  After-Care. — The  value  to  be 
derived  from  sanatorium  treatment,  whether  among  the 
industrial  classes  or  the  well-to-do,  depends  in  fact  upon 
the  efficiency  of  the  "after-care."  If  the  patient  returns 
to  the  unsatisfactory  conditions,  whether  in  his  work  or  at 
home,  under  which  he  acquired  the  disease,  the  improvement 
or  arrest  obtained  at  the  sanatorium  will  infallibly  be  of  short 
duration.  This  is  shown  in  the  better  results  obtained  by  Dr. 
Burton-Fanning^  at  the  Kelling  Sanatorium,  Norfolk,  where 
special  care  was  taken  from  the  first  to  obtain  suitable  em- 
ployment for  the  patients  after  their  discharge,  and  also  by  the 
similar  results  obtained  among  the  employes  of  the  Prussian 
and  Hessian  Railway  Companies^  quoted  in  our  last  edition. 

The  beneficial  effect  of  improving  the  work  and  environ- 
ment of  the  patient  has  also  been  recently  demonstrated  at  the 
Brompton  Hospital  Sanatorium  at  Frimley.  For  this  pur- 
pose the  late  Dr.  Meek,''  whose  untimely  death  is  much  to  be 
deplored,  contrasted  the  after-histories  of  two  groups  of 
patients,  in  whose  sputum  tubercle  bacilli  had  been  found, 
and  who  were  discharged  from  the  sanatorium  in  191 5. 
In  the  first  group,  32  in  number,  the  patients  were  dis- 
charged with  apparent  arrest  of  the  disease,  and  returned  to 
the  homes  and  working  conditions  under  which  they  had 
previously  broken  down.  Two  years  and  a  few  months  later 
15  (46-9  per  cent.)  were  still  at  work,  8  (25  per  cent.)  were 
alive  but  unable  to  work,  and  9  (28-1  per  cent.)  were  dead. 
In  the  second  group  of  cases  the  disease  was  somewhat  more 
extensive,  and  in  23  tubercle  bacilli  were  still  present  on  dis- 
charge, but  the  patients,  44  in  number,  left  the  sanatorium 
capable  of  doing  a  reasonably  full  day's  work,  and  having  a 
fair  chance  of  maintaining  working-capacity  in  healthy  sur- 
roundings. Of  these  44  patients,  29  effected  a  change  of  both 
residence  and  occupation,  5  a  change  of  occupation  only,  and 
10  found  situations  at  their  former  employment,  but  in  more 
suitable  localities.  In  most  instances  the  new  work  and  sur- 
roundings were  far  from  ideal,  but  constituted  a  marked  im- 
provement on  their  former  conditions.  After  a  few  months 
over  two  years,  35  (81-4  per  cent.)  were  well  and  at  work;  6 
(13-9  per  cent.)  were  well  and  at  work,  but  had  been  obliged 


622  DISEASES   OF   THE  LUNGS   AND   PLEUILE 

to  have  time  off  for  illness ;  i  (2-3  per  cent.)  was  fairly  well,  but 
not  at  work;  and  i  (2-3  per  cent.)  had  died. 

The  figures  quoted  show  the  value  of  improving  the  work 
and  environment  of  the  patient  on  his  return  home.  We 
have  similarly  been  much  impressed  by  the  manner  in  which 
patients,  whose  health  has  been  seriously  undermined  by  ex- 
tensive disease,  but  who  have  been  taken  on  to  the  permanent 
staff  of  the  sanatorium  and  have  thus  continued  to  hve  under 
the  best  conditions,  are  able  for  long  periods  to  retain  their 
health  and  working-  capacity.  Several  such  patients  are  on 
the  staff  of  the  Frimley  Sanatorium,  and  some  have  worked 
there  continuously  for  eleven  years.  In  another  instance  a 
skilled  engineer  was  under  the  care  of  one  of  us  at  the  Frimley 
Sanatorium  during  the  year  1908,  having  extensive  disease  of 
the  right  lung;  the  following  year  he  was  appointed  head 
engineer  at  one  of  our  best-known  sanatoria,  and  has  remained 
in  good  health,  working  there  continuously  ever  since. 

It  is  the  object  of  "  colonies,"  such  as  the  Cambridge- 
shire Tuberculosis  Colony  at  Papworth  Hall,  under  the 
supervision  of  Dr.  Varrier  Jones,  to  provide  the  patients  who 
go  to  live  there  with  suitable  work  under  the  best  hygienic 
conditions,  and  we  must  wish  success  to  this  and  similar  insti- 
tutions which  recognise  the  fundamental  importance  of  effi- 
cient after-care  in  the  treatment  of  phthisis. 

In  country  districts  the  inexpensive  shelters  of  wood  and 
canvas  desig^ned  by  Dr.  Lyster,*  of  Great  Baddow,  near 
Chelmsford,  which  can  be  erected  in  the  cottage  garden,  and 
in  which  patients  can  sleep,  are  helpful  in  promoting  the  con- 
tinuance of  the  after-care. 

Hints  in  Regard  to  Change  of  Work  and  Environment. — In 
advising  upon  the  question  of  any  change  in  work  and 
environment  after  the  patient  leaves  the  sanatorium,  care 
must  be  taken  in  the  first  place  to  see  that  the  new  work  will 
be  sufficient,  w4th  any  other  resources  available,  to  enable  the 
patient  to  obtain  a  living-  wage,  and  thus  the  full  nourish- 
ment which  his  case  requires.  For  this  reason,  as  we  have 
pointed  out  elsewhere,*  it  is  generally  a  mistake  to  advise  the 

patient  to  give  up  his  former  occupation  and  to  undertake, 

« 
*  The  following  paragraphs  are  quoted  from   an   address   delivered  by 
one  of  us  before  the  Inter-Allied  Conference  on  the  After-Care  of  Disabled 
Men,'  191 8. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  623 

without  any  previous  experience  or  training,  work  upon  the 
land.  The  wages  are  not  high,  the  housing  accommodation 
is  too  often  poor,  and  the  work  is  at  times  exceedingly 
arduous.  It  is  carried  on  also  under  conditions  of  exposure, 
and  the  hours  at  certain  seasons  are  very  long.  As  a  result, 
only  the  exceptional  case  can  stand  it  without  breaking  down, 
and  it  is  not  suitable  for  the  average  consumptive  on  leaving 
the  sanatorium.  We  may  add  that  it  is  not  a  life  which  pos- 
sesses g'reat  attractions  for  the  former  town-dweller. 

In  many  cases,  owing"  to  the  difficulty  of  finding  a  new  occu- 
pation, and  the  fact  that  under  such  circumstances  the  man 
will  at  first  be  untrained,  and  therefore  capable,  for  a  time 
at  least,  of  earning  only  a  low  wage,  the  wisest  course  is 
to  allow  the  patient  to  return  to  his  former  avocation,  pro- 
vided it  be  not  clearly  and  obviously  unsuitable  to  a  consump- 
tive patient,  changing,  hozvevcr,  the  environment  zvhenever 
possible.  Thus,  a  clerk  may  return  to  his  clerical  work,  but 
should  obtain,  if  possible,  a  post  in  the  country  or  at  the  sea- 
side. Similarly,  a  bank  clerk  may  often  be  transferred  to  a 
country  or  seaside  branch.  A  railway  porter  should  apply 
for  removal  from  a  city  to  a  country  station,  and  a  policeman 
to  a  suburban  division,  while  a  carpenter  may  obtain  work  as 
an  "estate  carpenter." 

Should  it  be  necessary,  owing  to  the  special  circumstances 
of  the  case,  to  find  a  fresh  occupation  for  a  patient,  then  one 
must  be  chosen  in  which  the  work  is  carried  on  under  good 
conditions,  and  as  much  in  the  open  air  as  possible.  When- 
ever possible,  too,  the  employe  should  be  to  some  extent  his 
own  master  in  regard  to  the  number  of  hours  worked  each 
day,  and  the  ability  to  take  a  day  off  from  time  to  time,  should 
he  not  be  feeling  quite  up  to  the  mark.  In  this  way  his 
strength  is  conserved,  and  the  danger  of  a  breakdown 
lessened. 

In  deciding  on  the  exact  occupation,  the  various  trades 
should  be  considered.  For  example,  in  the  building  trade  the 
work  of  a  painter  or  decorator,  a  builder,  a  bricklayer,  a  car- 
penter or  joiner  may  all  be  permitted,  by  preference,  however, 
in  a  smaller  rather  than  a  larger  town.  Wood-carving  or 
wood-road  laying  may  similarly  be  sanctioned. 

In  the  transport  trades  a  man  might  take  up  the  work  of 
a  coachman,  cab-driver,  chauffeur,  taxi-cab  driver,  motor-van 


624  DISEASES   OF   THE  LUNGS   AND   PLEURA 

driver  or  motor-cleaner,  but  experience  shows  that  the  work 
of  an  omnibus-  or  tram-conductor  or  driver  is  generally  too 
arduous  in  these  days  of  large  vehicles  and  rapid  driving. 
Railway-ticket-collecting-  and  certain  forms  of  mechanical 
work  on  the  railways  are  also  suitable. 

Although  the  work  of  an  agTicultural  labourer  is  not,  as  we 
have  seen,  to  be  advised,  certain  lighter  forms  of  work  on  the 
land  may  be  recommended,  such  as  market  and  flower-gar- 
dening, fruit-growing,  hurdle-making,  forestry  and  woodman's 
work.  The  occupation  of  a  game-keeper,  park-ranger,  park- 
attendant  or  lodge-keeper  is  also  excellent,  but  the  number 
of  such  posts  is  limited. 

Other  light  occupations  which  may  be  mentioned  are  those 
of  a  traveller,  an  insurance  or  commission-agent,  rent-collec- 
tor, canvasser  (though  in  individual  cases  they  may  involve 
too  many  hours'  walking),  commissionaire  and  bookstall- 
attendant.  Window-cleaning  is  not  to  be  recommended, 
owing-  to  possible  risk  of  haemorrhage. 

The  above  list  of  occupations  is  by  no  means  exhaustive, 
and  is  given  only  as  an  indication  of  the  kind  of  occupation 
which  may  be  recommended.  For  married  men,  we  have 
often  suggested  that,  if  the  wife  is  capable  and  has  some 
knowledge  of  country  life,  some  business,  in  which  she  can 
assist,  may  be  entered  u^on  in  a  country  or  village  district. 

We  have  drawn  attention  to  the  fact  that  relapse  is  only 
too  common  if  the  patient  returns  to  the  depressing  conditions 
under  which  he  acquired  the  disease.  The  converse  is  also 
trife,  and  Dr.  Picken  has  drawn  attention  to  the  fact  that  not 
a  few  soldiers  who  first  showed  evidence  of  phthisis  in  the 
army,  and  who  had  tubercle  bacilli  in  the  sputum,  are  still 
working  regularly  a  year  or  two  after  discharg-e,  and  without 
having-  had  the  benefit  of  sanatorium  treatment.  In  many  the 
physical  signs  would  now  appear  to  be  very  slight.  This 
result,  as  Dr.  Picken"  suggests,  may  well  be  attributable  to 
early  recognition  and  acceptance  of  the  disease,  and  also  to 
the  fact  that  many  of  the  patients  possessed  a  fairly  strong 
natural  immunity  to  tuberculosis,  and  only  contracted  the 
disease  under  abnormal  war  conditions  of  mental  and  physical 
strain  and  exposure  to  infection.  When  removed  from  these 
conditions,  the  natural  recuperative  powers  effect  a  cure. 
The   Value   of  Sanatorium  Treatment  am,ong  the  Indus- 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  625 

trial  Classes. — It  is  pertinent  now  to  ask  how  the  results  of 
sanatorium  treatment  among  the  working  classes  compare 
with  those  met  with  in  patients  of  a  similar  class  who  have 
not  had  the  advantage  of  institutional  treatment. 

Such  a  comparison  is  by  no  means  easy  to  make,  since 
adequate  data  are  not  available.  Moreover,  with  improved 
medical  treatment  and  the  generally  increased  well-being  of 
the  industrial  classes,  coincident  with  the  rise  in  wages  which 
took  place  in  the  latter  half  of  the  nineteenth  century,  the 
prognosis  of  consumption  has  improved  materially  since 
Laennec  and  Louis  a  century  ago  placed  the  duration  of  the 
disease  at  about  two  years.  Even  in  1849,  when  the  first 
medical  report  of  the  Brompton  Hospital  was  published,  the 
outlook  was  not  much  better  than  in  Laennec's  time,  for 
of  215  cases  which  had  terminated  fatally  in  the  hospital,  the 
duration  of  168  (78' i  per  cent.)  was  under  two  and  a  half 
years,  and  only  6" 5  per  cent,  of  the  patients  lived  longer  than 
four  years.  Sixteen  years  later  the  researches  of  our  late 
colleague.  Dr.  Pollock,"  showed  that  the  outlook  was  more 
favourable.  Of  3,566  phthisical  patients  observed  by  him, 
only  129  (3-6  per  cent.)  had  died  within  two  and  a  half  years; 
in  the  remainder  the  condition  of  the  patients  was  still  on  the 
whole  "favourable  to  the  expectation  of  hfe  for  a  considerable 
term." 

In  1903  Dr.  Stadler,^^  of  Marburg,  from  his  observation  of 
670  male  and  female  patients  during  the  years  1893-1901,  was 
led  to  place  the  mean  duration  of  life  in  cases  of  phthisis 
occurring  among  the  working-class  population  of  Marburg 
and  its  neighbourhood  at  between  six  and  seven  years. 

Messrs.  Elderton  and  Perry,^^  working  under  the  auspices 
of  Professor  Karl  Pearson,  pubHshed  in  1910  a  statistical 
memoir  dealing  with  this  subject,  in  which  they  compared  the 
results  from  sanatorium  treatment  with  those  obtained  in  pre- 
sanatorium  days,  using  for  the  latter  the  data  collected  by 
the  late  Dr.  Pollock  and  the  late  Dr.  Theodore  Williams.  It 
should  be  noted,  however,  that  the  patients  of  Dr.  Williams 
were  private  cases,  and  did  not  belong  to  the  working  classes. 
The  conclusion  arrived  at  was  that  "the  mortality  among 
sanatorium  patients  does  not  show  any  improvement  over 
that  of  earlier  days."  The  authors  admit,  however,  that  the 
comparisons  are  difficult  by  reason  of  the  way  in  which  the 

40 


626  DISEASES   OF   THE  LUNGS   AND   PLEURA 

older  figures  were  given.  In  a  more  recent  publication  deal- 
ing with  the  private  patients  of  the  late  Dr.  Austin  Flint  in 
the  United  States  between  1845  ^^^  1870,  Messrs.  Elderton 
and  Perry ^*  draw  attention  to  the  fact  that  for  reasons  given 
any  comparison  between  sanatorium  results  and  presana- 
torium  records  is  open  to  considerable  criticism,  and  conclude 
that,  while  hoping  and  thinking  that  some  improvement  has 
taken  place,  it  is  far  less  than  has  sometimes  been  stated. 

Our  own  experience  would  lead  us  to  the  conclusion  that 
for  incipient  and  early  stage  cases  amongst  the  industrial 
classes  superior  immediate  results  are  obtained  in  sanatoria, 
and  that  those  results  may  be  maintained  for  many  years 
under  favourable  conditions  of  working  life.  The  securing 
of  these  conditions  constitutes  the  grave  problem  to  be  faced, 
and  to  this  subject  we  have  referred  above. 

Sanatoria  for  the  industrial  classes  are  not  adapted  for 
patients  with  advanced  disease,  nor  for  cases  of  pulmonary 
tuberculosis  in  an  acute  stage,  nor  for  those  more  active  cases, 
numbering,  perhaps,  some  10  per  cent,  of  the  whole,  which 
steadily  progress  in  spite  of  every  form  of  treatment.  Such 
patients  are  better  in  a  hospital,  and  we  believe  that  the  best 
results  can  only  be  obtained  when,  as  at  Brompton,  the  sana- 
torium and  hospital  are  hnked  together.  In  the  hospital  the 
patients  can  be  carefully  observed  and  g'rouped,  those  with 
fever  and  active  disease  being  treated  and  nursed  at  the  parent 
institution,  those  in  an  early  and  more  quiescent  stage,  in 
whom  a  few  v/eeks'  observation  gives  promise  of  arrest  of 
the  disease,  being  drafted  to  the  sanatorium.  For  patients 
with  advanced  disease  further  accommodation  is  required, 
and  some  suitable  modification  of  portions  of  our  existing 
poor-houses  and  infirmaries  might  easily  be  effected  to  assist 
in  meeting  the  requirements. 

Results  of  Sanatorium  Treatment  among  the  Wealthier 
Classes. — In  patients  belonging  to  the  wealthier  classes,  whose 
circumstances  after  leaving  home  are,  as  a  rule,  much  more 
favourable  for  the  maintenance  of  health,  the  outlook,  as 
might  be  expected,  is  more  hopeful.  Dr.  Noel  Bardswell,'' 
in  1910,  published  the  results  which  he  obtained  at  the  Mundes- 
ley  Sanatorium  in  regard  to  the  241  male  and  female  patients 
treated  by  him  at  that  institution  during  the  five  years  1901 


TREATMENT  OF  PULMONARY  TUBERCULOSIS 


627 


to  1905.  These  patients  were  unselected,  and  were  admitted 
consecutively.  His  figures  demonstrate  clearly  that  with  the 
well-to-do,  as  with  the  poor,  the  best  results  can  only  be  looked 
for  if  treatment  is  commenced  early.  If  also  we  examine  the 
early  or,  as  they  are  called,  incipient  cases,  following  the 
American  method  of  classification,  and  note  the  results  on 
January  i  of  the  fifth  year  after  treatment  in  those  discharged 
during. the  period  1901  to  1904,  we  obtain  results  which  are 
comparable  with  those  which  we  have  already  quoted.  We 
find  in  this  way  that  of  54  patients  belonging  to  this  group, 
48,  or  88"8  per  cent.,  were  still  aHve  and  fit  for  work  between 
four  and  five  years  after  their  discharge,  as  compared  with 
the  approximate  figures  50  and  60  per  cent,  obtained  at  the 
Stanhope  and  Kelling-  Sanatoria. 

The  results  obtained  over  a  period  of  twenty-one  years  at 
Dr.  Trudeau's  "  Adirondack  Cottage  Sanitarium "  in  New 
York  State,  an  institution  which  in  some  respects  resembles 
the  King  Edward  VII.  Sanatorium  at  Midhurst,  though  the 
patients  are  of  a  somewhat  higher  social  standing,  were 
analysed  statistically  by  Dr.  Lawrason  Brown  and  the  late 
Mr.  E.  G.  Pope.'^  They  refer  to  2,261  patients  admitted  in 
all  stages  of  the  disease.  The  immediate  results  were  as 
follows : 


Table  showing  the  Condition  on  Discharge  of  2,222  Patients  admitted 
INTO  THE  Adirondack  Cottage  Sanitarium,  New  York  State,  U.S.A. 


Condition  on  Admission. 

Number  of 
Patients. 

Condition  on  Discharge. 

Apparently- 
Cured 
(per  Cent.). 

Disease 

Arrested 

(per  Cent.). 

Disease 

Active 

(per  Cent.). 

Died  in  the 
Sanitarium 
(per  Cent.). 

Incipient  cases 

Moderately  advanced  ... 
Far  advanced 

620 

1.329 

273 

56 
12 

3'- 
46 
16 

II 

40 
78 

0"03 
2-00 
6  "00 

The  above  figures  demonstrate  once  again  that  for  even  the 
immediate  results  to  be  successful  treatment  must  be  com- 
menced early.  They  also  bring  out  the  important  fact,  to 
which  we  have  already  referred,  that  even  in  early  cases  arrest 
is  not  by  any  means  a  certainty.     Thus,  of  the  620  "  incipient" 


628 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


cases,  68,  or  ii  per  cent.,  were  discharged  with  the  disease 
still  showing  signs  of  activity. 

The  further  results,  showing  the  after-histories  of  those 
who  left  the  sanatorium  (a)  "apparently  cured"  (519  cases), 
(b)  with  "disease  arrested"  (890  cases),  (c)  with  "active 
disease  "  (835  cases),  may  perhaps  be  best  set  forth  in  the  fol- 
lowing diagram,  taken  from  Dr.  Lawrason  Brown  and  Mr. 
Pope's  paper.  The  curves,  based  upon  the  Adirondack 
figures,  show  for  1,000  persons  of  each  of  the  three  groups, 
the  numbers  surviving  at  the  end  of  successive  years,  the 
curves  so  obtained  being  compared  with  the  expected  death- 
rate  of  the  general  population. 

Diagram  showing  the  Numbers  surviving  at  the  End  of  Each  Year, 
OUT  OF  (I.)  1,000  Persons  in  the  General  Population;  (II.)  1,000 
discharged  "Apparently  Cured"  from  the  Adirondack  Cottage 
Sanitarium;  (III.)  1,000  discharged  "Arrested";  (IV.)  1,000  dis- 
charged with  "  Active  Disease." 


900 

too 

JOO 
600 

too 
too 

300 

too 

VO 
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If  we  study  the  curves  shown  above,  it  will  be  seen  that  the 
patients  who  have  been  discharged  "  apparently  cured " 
(Curve  II.)  possess  an  outlook  of  a  very  hopeful  kind,  the 
number  surviving  at  the  end  of  fifteen  years  being  about  750 
out  of  every  1,000,  as  opposed  to  850  per  1,000  of  the  general 
population.  A  glance  at  the  table  on  the  preceding  page  will, 
moreover,  show  that  of  the  620  patients  admitted  in  the  in- 
cipient stage  of  the  disease,  whom  careful  diagnosis  should  at 
the  present  day  at  once  bring  under  treatment,  56  per  cent., 
or  more  than  half,  were  discharged  "apparently  cured,"  and 
possess  therefore  this  favourable  prognosis. 

Curve  III.  further  reveals  that  the  patients  who  were  dis- 
charged with  "arrested"  disease,  which  group  includes  32  per 
cent,  of  the  incipient  cases,  still  possessed  an  average  expec- 


TREATMENT   OF   PULMONARY  TUBERCULOSIS  629 

tancy  of  life  of  between  seven  and  eight  years.  In  only 
II  per  cent,  of  early  cases  was  the  outlook  gloomy,  as  shown 
by  the  rapid  fall  to  the  base  line  of  Curve  IV. 

Such  results  are  satisfactory,  and  demonstrate  what  may 
be  hoped  for  from  sanatorium  treatment  in  the  upper  classes, 
whose  members  are  able  to  carry  on  the  treatment  after  leav- 
ing the  institution,  and  in  whom  the  disease  has  been  detected 
and  brought  under  treatment  in  an  early  stage.  With  the 
more  advanced  cases  the  future  is  proportionately  less  bright. 

Data  derived  from  the  Records  of  the  King  Edward  VII. 
Sanatorium,  Midhurst. — A  newer  method  of  estimating*  the 
results  of  sanatorium  treatment  was  followed  by  Dr.  Noel 
BardswelV^  in  collaboration  with  Mr.  J.  H.  R.  Thompson, 
a  Fellow  of  the  Institute  of  Actuaries,  under  the  auspices 
of  the  Council  of  King  Edward  VII.  Sanatorium,  Mid- 
hurst, and  carried  on  since  1914  with  the  countenance 
and  aid  of  the  Medical  Research  Committee  of  the 
National  Health  Insurance,  who  have  borne  the  expense 
of  publishing  the  results.  The  lines  of  the  investiga- 
tion are  similar  to  those  adopted  by  Messrs.  Elderton  and 
Perry^*  in  their  study  of  the  results  obtained  at  the 
Adirondack  Sanitarium  to  which  we  have  alluded.  The 
cases  are  grouped  "  i,"  "2,"  "3"  for  each  sex,  according  as 
they  are  in  the  "incipient,"  "moderately  advanced,"  or  "far 
advanced"  stage.  The  cases  include  all  those,  1,707  in  num- 
ber, which  were  discharged  from  the  sanatorium,  after  not  less 
than  eight  weeks'  treatment,  during  the  eight  years  1907-1914. 
With  such  diligence  has  the  inquiry  into  the  after-history  of 
the  cases  been  prosecuted  that  in  only  3-5  per  cent,  has  it 
failed  to  be  obtained.  The  important  feature  in  the  inquiry  is 
the  comparison  made  at  each  year  of  the  mortaHty  among  the 
various  groups  of  patients  with  that  which  would  have  been 
expected  had  the  groups  been  samples  of  the  general  popula- 
tion corresponding  as  to  age  and  sex.  We  must  refer  the 
reader  to  the  full  report,  with  its  numerous  elaborate  tables, 
and  need  here  only  give  the  results.  They  are  briefly  as 
follows : 

I.  The  mortality  experienced  by  patients  after  sanatorium 
treatment  is  very  heavy,  the  death-rate,  even  for  patients 
admitted  in  the  early  stage  (group  i),  being  nearly  six  times, 
that  of  patients  admitted  with  moderately  advanced  disease 


630 


DISEASES   OF  THE  LUNGS   AND   PLEURA 


(group  2),  over  sixteen  times,  and  that  of  patients  admitted 
with  far  advanced  disease  (group  3)  thirty-eight  times  greater 
than  the  rate  for  the  population  of  England  and  Wales. 

2.  The  results  for  male  and  female  patients  show  no  material 
difference,  but  the  mortality  is  relatively  greater  at  the  younger 
ages  at  discharge. 

3.  The  results  at  Midhurst  are  generally  similar  to,  and  are 
confirmed  by,  those  obtained  by  Messrs.  Elderton  and  Perry^* 
from  their  actuarial  investigation  of  the  patients  at  the 
Adirondack  Sanitarium  in  New  York  State  to  which  we  have 
already  referred. 

4.  Another  important  conclusion  is  that  the  mortality  is 
greatest  during  the  first  two  or  three  years,  following  dis- 
charge, the  excess  mortality  being  subsequently  materially 
reduced,  so  that  for  group  i  at  least  the  rates  for  durations 
of  six  to  eight  years  after  discharge  are  not  seriously  above 
the  normal.  This  is  shown  in  the  following  diagram  taken 
from  Dr.  Bardsweli  and  Mr.  Thompson's  paper : 


JO- 

Groufl  I 

Ma/es     ,      . . 

—  -^ 

Croup  Z 
'        \      Fema/es 

— Jf 
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en 

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— . , — . . — . i — . 4 — 

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o     /      !     3       *      s      e      7      e 


z       3      a     i       6      r       B 


Number  of  Years  elapsed  since  Discharge. 

Fig.  64. — Diagram  showing  the  Ratio  of  Actual  to  Expected  Deaths, 
determined  according  to  the  number  of  years  which  have  elapsed 
SINCE  Discharge  from  the  Sanatorium,  and  indicating  that  the 
Mortality  is  greatest  during  the  First  Three  Years,  and  that 
this  Period  is  therefore  the  Critical  One  from  the  After-History 
Point  of  View. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  63 1 

It  follows  from  the  above  that  the  first  three  years  are  the 
"  critical  period  "  for  patients  after  discharg'e,  and  that  during 
this  time  they  must  take  no  liberties  with  themselves,  but  do 
all  in  their  power  to  continue  to  live  on  sanatorium  lines. 

5.  Another  valuable  conclusion  is  that  for  patients  dis- 
charged with  the  disease  arrested,  the  subsequent  mortality  is 
not  very  different  for  groups  i,  2,  and  3,  showing  that  in  such 
cases  the  extent  of  the  disease  on  admission  is  of  minor  im- 
portance ;  but  that  on  discharge,  if  the  disease  be  not  arrested, 
the  condition  at  the  commencement  of  treatment  g'overns  the 
prospect  of  longevity.  Thus  in  making  a  prognosis  the  con- 
dition on  discharge  is  at  least  of  equal  importance  to  that  on 
admission. 

6.  In  their  report  Dr.  Bardswell  and  Mr.  Thompson  show 
that  in  two-thirds  of  the  patients  the  disease  commenced 
insidiously,  and  in  one-fifth  with  haemoptysis,  and  that  in  the 
latter  patients  the  mortahty  experienced  was  lighter.  This 
is  in  accordance  with  general  experience,  and  is  due  in  part 
at  least  to  the  early  recognition  of  the  disease  which  haemo- 
ptysis entails,  and  the  more  prompt  treatment  which  generally 
follows. 

7.  As  might  be  expected,  the  records  prove  that  patients 
with  laryngeal  as  well  as  pulmonary  tuberculosis  experience 
substantially  higher  rates  of  mortality  than  cases  not  so  com- 
plicated; but  in  the  comparatively  uncommon  cases  of  early 
laryngeal  tuberculosis,  associated  with  but  sHght  lung-  trouble, 
the  outlook  is  not  unfavourable. 

8.  The  results  further  show  that  the  prognosis  is  materially 
improved  if  tubercle  bacilH  disappear  from  the  sputum  before 
discharge.  Whenever  possible,  therefore,  treatment  should 
be  continued  until  a  negative  sputum  has  been  obtained. 

9.  Lastly,  it  is  interesting  to  note  that,  as  Messrs.  Elderton 
and  Perry^*  also  found  in  their  study  of  the  Adirondack 
patients,  the  prognosis  in  a  g-iven  case  is  not  made  worse  by  a 
consumptive  family  history.  Messrs.  Elderton  and  Perry  point 
out  that  this  does  not  mean  that  the  children  of  tuberculous 
parents  are  ,not  more  likely  to  acquire  the  disease  than  patients 
without  such  family  history,  but  that  if  an  individual  possesses 
the  type  of  constitution  suitable  for  the  development  of  tuber- 
culosis, it  is  immaterial  whether  such  constitution  is  traceable 
to  the  parents  or  due  to  disease  or  some  other  cause. 


632  DISEASES   OF   THE   LUNGS    AND   PLEUR/E 

In  conclusion,  we  would  repeat  that  we  have  for  clearness' 
sake  spoken  above  of  sanatorium  treatment  as  representing 
treatment  in  a  sanatorium.  We  have  already,  however,  pointed 
out  that  a  certain  proportion  of  the  well-to-do  can  secure  the 
conditions  of  such  treatment  in  their  own  homes,  or  at  least 
can  secure  the  after-care  treatment  on  the  same  lines  at  an 
earlier  period  and  for  a  longer  time  than  can  less  favoured 
persons.  Indeed,  we  would  urge  that  sanatorium  treatment 
is  only  the  enforcement  of  proper  hygienic  measures  under 
medical  supervision. 

It  will  be  within  the  experience  of  physicians  to  have  seen 
cases  of  pulmonary  tuberculosis  amongst  both  out-patients  and 
the  better  classes  who,  without  any  formal  sanatorium  treat- 
ment, but  simply  acting  under  advice,  have  recovered  from 
this  malady.  We  are  ourselves  aware  of  many  such  cases  of 
complete  recovery,  standing  the  test  of  twenty  to  thirty  years 
of  time,  and  it  may  be  of  interest  to  quote  the  two  following, 
in  each  of  whom,  however,  climatic  change  formed  an  element 
in  the  treatment : 

Case  I. — Mrs.  X.  consulted  Dr.  Douglas  Powell  in  October, 
1891,  on  account  of  some  haemoptysis.  There  had  been  pre- 
ceding symptoms  of  only  a  few  weeks'  duration.  The  physical 
signs  showed  early  lesion  at  one  apex,  but  the  sputum  revealed 
the  presence  of  tubercle  bacilli  in  fair  numbers.  The  lady  went 
to  St.  Moritz  in  November,  and  remained  there  for  the  winter. 
She  greatly  improved,  and  completely  lost  her  cough.  She  lived 
a  careful  life  under  Dr.  Holland's  observation  at  St.  Moritz, 
but  was  under  no  "  sanatorium  "  regime.  She  returned  to  St.  Moritz 
in  January  of  the  following  year  for  a  couple  of  months  as  a  measure 
of  precaution,  but  not  on  account  of  any  return  of  symptoms.  She 
resumed  her  professional  work.  In  1894  she  again  came  under  obser- 
vation with  a  severe  attack  of  enteric  fever  with  relapse,  and  has 
since  then  passed  through  other  severe  illnesses.  She  has  never, 
however,  had  any  return  of  chest  symptoms,  and  is  now  (1920) 
in  fairly  good  health,  having  recently  accomplished  a  visit  to 
America. 

Case  II. — An  ofificer,  aged  35,  had  a  severe  hasmoptysis  in 
1887,  followed  by  cough  and  expectoration,  with  tubercle  bacilli 
present  in  the  sputum,  and  other  symptoms  of  early  tuber- 
culosis. There  were  pyrexial  signs,  dulness  and  slight  crepita- 
tion at  the  right  apex.  He  was  a  man  of  athletic  build,  6  feet  2  inches, 
although  rather  narrow-chested  for  his  height.  After  a  period  of 
treatment  he  went  by  sailing-ship  round  the  Cape  to  Australia  and 
New  Zealand,  starting  at  the  end  of  September,  arriving  in  Melbourne 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  633 

on  December  22.  He  returned  by  steamer,  spent  a  short  time 
at  Aix-Ies-Bains,  and  arrived  home  at  the  end  of  May,  1888.  He 
did  not  gain  much  by  the  voyage,  and  spent  the  winter  of  1888-89  at 
St.  Moritz,  with  benefit,  and  the  following  winter  on  the  Riviera,  and 
after  that  went  to  India  and  round  the  world.  There  were  no  sana- 
toria available  in  those  days,  but  he  was  a  man  of  temperate  habits 
and  self-restraint,  and  led  a  careful  sanitary  life.  By  advice  he  relin- 
quished the  army  on  his  return  from  abroad  and  went  to  live  on 
his  own  estate  in  the  North,  and  having  all  the  attributes  of  a  sports- 
man and  a  country  gentleman,  he  spent  his  leisure  time  fishing,  shoot- 
ing, etc.  He  regained  health,  and  in  course  of  time  he  could  out-walk 
his  keepers  grouse-shooting,  shooting  over  dogs,  and  deer-stalking. 
Except  for  an  occasional  attack  of  influenza,  his  health  has  remained 
excellent. 

In  January,  19 19,  he  had  a  bad  attack  of  influenza  with  bronchitis, 
and  on  one  occasion  in  the  earlier  days  of  this  attack  a  specimen  of 
sputum  sent  for  examination  by  his  medical  adviser  was  reported  to 
contain  "  a  very  few  tubercle  bacilli."  On  another  examination  within 
a  week,  however,  the  report  was  negative,  and  when  seen  by  one  of 
us  at  the  end  of  February  the  report  on  a  specimen  of  sputum  was 
"  no  tubercle  bacilli  were  seen  in  this  mucous  sputum  after  a  pro- 
longed search."  He  had  completely  recovered,  and  there  were  no 
physical  signs  beyond  slight  impairment  of  percussion  note  over  the 
right  apex.     He  was  now  67  and  leading  the  same  active  country  life. 

Here  is  a  case  of  recovery  from  tuberculosis  and  acquired  immunity 
of  thirty-two  years'  duration,  developed  under  healthy  conditions  of  life 
and  maintained  under  medical  advice  intelligently  pursued,  although 
not  with  the  system  and  formality  of  sanatorium  therapy.  We  have 
no  doubt  that  the  visit  to  the  Engadine  started  the  cure,  as  has  been 
the  case  with  others  in  our  experience.  Assuming  the  accuracy  of 
the  report  as  to  the  presence  of  a  few  bacilli  on  one  occasion  during 
the  last  influenzal  attack,  we  do  not  think  it  a  matter  for  surprise, 
although  when  examined  on  other  occasions,  and  within  a  week  and 
again  in  a  month,  no  bacilli  were  found,  for  it  is  quite  conceivable 
that  a  catarrhal  attack  affecting  an  old  quiescent  lesion  might  loosen 
from  it  some  effete  products  containing  bacilli.  In  any  case,  the 
immunity  is  shown  in  their  failure  to  gain  ground. 

We  have  alluded  to  other  cases  treated  on  similar  lines  and 
enjoying  many  years  of  immunity,  and  we  might  mention  not 
a  few  more,  some  with  a  very  considerable  degree  of  lesion, 
but  they  by  no  means  invalidate  our  opinion  that,  taking 
numbers,  and  considering  the  conditions  under  which  tubercu- 
losis is  most  generally  acquired  and  prevalent,  sanatorium 
treatment  is  the  best  and  most  rational  average  treatment  of 
the  disease.  We  only  note  that  many  isolated  cases  have 
informally,  and  as  it  were  by  chance,  by  the  adoption  of  some- 


634  DISEASES   OF   THE  LUNGS   AND   PLEURA 

what  similar  lines,  foimd  immunity.  One  result  of  the  institu- 
tional treatment  of  phthisis  has  been  to  educate  the  public 
and  the  profession  in  sanitary  methods  of  self-management  in 
this  disease,  and  to  it  we  owe  much  of  the  improvement  of 
those  who  do  not  rigorously  adopt  the  regime. 

REFERENCES. 

^   (a)   On  Sanatoria  for   Consumftion  and  Certain   Other  Asfects  of  the 
Tuberculosis  Question^  by  H.  Timbrell  Bulstrode,  M.D.,  Supplement 
to  the  Report  of  the  Medical  Officer  to  the  Local  Government  Board 
for   1905-1906.     London,   1908. 
[b]  Loc.   cit.,  p.  664. 

^  See  Tenth  Annual  Re  fort  of  the  Society  for  the  Prevention  and  Cure 
of  Consum-ption  in  the  County  of  Durham.     Sunderland,  1909. 

^  The  O fen-Air  Treatment  of  Pulmonary  Tuberculosis,  by  F.  W.  Burton- 
Fanning,  M.D.,  second  edition,  p.   147.     London,  1909. 

*  Statistic  der  Heilbehajidlung  bei  den  Versicherungsanstalten  und 
zugelassenen  Kasseneinrichtungen  der  Invalidenversicherung  fiir  die  Jahre 
1904,  1905,  1906,  1907,  1908,  Amtliche  Nachrichten  des  Reichs- 
Versicherungsamts,  1909,  2  Beiheft,  s.  9^-96.     Berlin,  1909. 

^  Heilbehandlung  von  Versicherten  und  Fiirsorge  fiir  Invalide  bei  der 
Landes-V ersicherungsanstalt  der  Hansestddte  im  Jahre  1908,  s.  24,  Liibeck, 
1909. 

®  Pensionskasse  fiir  die  Arbeiter  der  Preussisch-H essischen  Eisenbahn- 
gemeinschaft.  Jahresbericht,  1908,  s.  8.  Druck  von  H.  S.  Hermann, 
Berlin. 

'  "  The  Value  and  Limitations  of  Sanatorium  Treatment  as  regards  the 
Working  Classes,"  by  W.  O.  Meek,  M.S.,  S.B.,  The  Lancet,  1917,  vol.  ii., 

P-  785- 

*  See  "  The  Tuberculosis  Problem  in  County  Areas,"  by  A.  H.  Hogarth, 
M.B.,  British  Medical  Journal,  1910,  vol.  ii.,  p.  596. 

'  "The  Care  of  the  Tuberculous  Soldier,"  by  Major  P.  Horton-Smith 
Hartley,  C.V.O.,  M.D.,  F.R.C.P.,  Reforts  of  the  Inter-Allied  Conference 
071  the  After-Care  of  Disabled  Men,  London,  1918,  p.  266. 

^"  "  The  Expectation  of  Life  in  Pulmonary  Tuberculosis,  with  Special 
Reference  to  Pension  Assessment,"  by  Ralph  M.  F.  Picken,  M.B.,  D.P.H., 

The  Lancet,   1919,   vol.   ii.,   p.    106. 

"  The  Elements  of  Prognosis  in  Consumftion,  by  James  Edward  Pollock, 
M.D.,  p.  70.     London,  1865. 

^^  "  Der  Einfluss  der  Lungentuberkulose  auf  Lebensdauer  und  Erwerbs- 
fahigkeit  und  der  Werth  der  Volksheilstatten-behandlung,"  von  Dr.  Ed. 
Stadler,  Deutsches  Archiv  fiir  Klinische  Medicin,  1903,  Band  Ixxv.,  p.  412. 

'^  A  Third  Study  of  the  Statistics  of  Pulmonary  Tuberculosis.  The 
Mortality  of  the  Tuberculous  and  Sanatorium  Treatment  (Drapers'  Com- 
pany Research  Memoirs),  by  W.  Palin  Elderton,  F.I. A.,  and  S.  J.  Perry, 
A. LA.     London,  1910. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  635 

'■*  A  Fourth  Study  of  the  Statistics  of  Pulmonary  Tuberculosis :  the 
Mortality  of  the  Tuberculous :  Sanatorium  and  Tuberculin  Treatment,''''  by 
W,  Palin  Elderton,  F.LA.,  and  Sidney  J.  Perry,  A. LA.     London,  1913. 

"  The  Expectation  of  Life  of  the  Consumftive  after  Sanatorium  Treat- 
ment, by  Noel  D.  Bardswell,  M.D.,  p.   12,  etc.     London,  1910. 

"  "  The  Ultimate  Test  of  the  Sanatorium  Treatment  of  Pulmonary 
Tuberculosis,  and  its  Application  to  the  Results  obtained  in  the  Adirondack 
Cottage  Sanitarium,"  by  Lawrason  Brown,  M.D.,  and  E.  G.  Pope, 
Zeitschrift  fiir  Tuberkulose,  1908,  Band  xii.,  Heft  3. 

"  Pulmonary  Tuberculosis :  Mortality  after  Sanatorium  Treatment. 
A  Report  on  the  Experience  of  the  King  Edward  VII .  Sanatorium,  Mid 
hurst,  by  Noel  D.  Bardswell,  M.V.O.,  M.D.,  F.R.C.P.,  and  John  H.  R. 
Thompson,  F.LA.  National  Health  Insurance,  Medical  Research  Com- 
mittee, London,  1919. 


CHAPTER  XLV 

ON  CLIMATIC  CHANGE  IN  THE  TREATMENT  OF  PULMONARY 

TUBERCULOSIS 

We  must  preface  what  we  have  to  say  in  regard  to  the 
benefits  to  be  derived  from  climatic  changes  with  the  warning 
that,  owing  to  recent  legislative  enactments,  the  scope  of  this 
valuable  method  of  treatment  has  been  considerably  curtailed. 
In  the  Dominions  of  Australia  and  New  Zealand,  in  Canada 
and  the  United 'States,  the  immigration  laws  now  forbid  suf- 
ferers from  tuberculosis  to  enter  the  country  if  the  disease  be 
in  an  infectious  stage,  and  at  the  present  time  (May,  1920)  the 
subjects  of  pulmonary  tuberculosis,  in  whatever  stages,  are 
not  allowed  admission  into  the  Union  of  South  Africa.  Pre- 
cautions are  also  taken  to  insure  that  no  patient  shall  become 
a  charge  upon  public  funds.  In  every  case,  therefore,  we 
should  advise  the  intending  traveller  or  settler  to  take  the 
precaution  of  communicating  before  he  leaves  England  with 
the  chief  medical  officer  of  the  Commonwealth  Medical 
Bureau  at  Australia  House,  Strand,  or  the  corresponding 
authorities  attached  to  the  New  Zealand,  Canadian,  United 
States  and  South  African  Emigration  Offices  in  London,  so 
as  to  assure  himself  that  he  will  be  permitted  to  land  on 
arrival  at  his  journey's  end. 

It  should  be  borne  in  mind  also  that,  although  the  ensuing 
pages  are  written  more  especially  with  reference  to  pulmonary 
tuberculosis,  all  other  chest  diseases  in  which  change  of 
climate  is  desirable  are  taken  into  account. 

We  have  seen  in  the  last  chapter  that  in  the  majority  of 
cases  of  early  phthisis  it  is  well  to  recommend,  for  a  time  at 
least,  sanatorium  treatment.  By  this  means  the  patient  is 
taught  in  a  practical  manner  how  best  to  conduct  his  life,  and 
is  safely  guided  through  the  earlier  and  often  febrile  period 

636 


ON  CLIMATIC  CHANGE  637 

of  his  disease,  during  which,  without  the  minute  and  careful 
supervision  which  forms  so  essential  a  feature  of  the  sana- 
torium regime,  he  would  be  liable,  through  imprudence  or 
ignorance,  to  aggravate  his  trouble. 

Until  the  more  acute  symptoms  have  completely  passed 
away  and  the  malady  has  become  quiescent,  a  sanatorium  in 
England,  which  does  not  involve  a  long  journey,  is  to  be 
preferred.  When,  however,  after  some  months,  this  stage 
has  passed,  and  when  the  temperature  has  become  normal, 
and  remains  so  even  after  a  considerable  degree  of  exercise, 
then  cHmatic  change,  whether  combined  with  further  sana- 
torium treatment  or  not,  may  be  considered. 

The  climatic  resorts  to  which  such  patients  may  be  sent 
differ  with  the  time  of  year,  the  nature  of  the  case,  and  the 
temperament  of  the  patient.  It  is  difficult  at  the  present 
moment  to  classify  these  resorts  with  exactness;  but  there 
are  certain  indications  for  selection  generally  applicable, 
which  we  will  endeavour  to  point  out. 

Elevated  Climates  (above  3,000  Feet). — The  first  ques- 
tion which  often  presents  itself  for  decision  is  whether  to  send 
the  patient  to  an  elevated  chmate  or  not.  It  will  clear  the 
ground,  therefore,  if  we  first  briefly  consider  these  climates, 
and  the  cases  that  should  and  should  not  be  sent  to  them. 

Alpine  Stations.— The  most  important  of  these  are  Davos 
(S,ioo  feet)  and  Arosa  (5,900  feet)  in  the  Canton  Orisons; 
St.  Moritz  (6,000  feet)  in  the  Upper  Engadine;  Montana 
(5,000  feet),  above  Sierre,  in  the  Canton  Valais;  and  Ley  sin 
(4,800  feet),  not  far  from  Aigle  and  the  Lake  of  Geneva.  At 
a  lower  level,  and  therefore  with  a  somewhat  milder  climate, 
we  may  mention  Les  Avants  (3,200  feet),  Caux  (3,500  feet), 
and  Chateau  d'CEx  (3,260  feet),  all  situated  in  the  Canton 
Vaud,  not  far  from  Montreux. 

At  Davos  there  are  various  sanatoria  to  which  the 
patient  may  be  sent,  if  thought  desirable,  including  the 
one  upon  the  Schatzalp,  situated  1,000  feet  above  Davos 
itself;  there  are  also  good  hotels  fairly  well  adapted  for 
pursuing  sanatorium  lines  of  treatment.  At  Arosa  there 
are  several  sanatoria  and  good  hotels.  At  Montana  the 
Palace  Hotel,  originally  built  as  a  sanatorium,  has  been 
recently  reconverted  to  its  original  use,  and  is  now  run  on 
sanatorium    lines;   the    cHmate   is    very   dry,    with   abundant 


638  DISEASES   OF   THE  LUNGS   AND   PLEURA 

sunshine,  but  the  air  is  not  so  still  as  at  Davos.  St.  Moritz  is 
better  adapted  for  increasing  the  resistance  of  persons  not  as 
yet  actually  attacked.^ 

It  is  during  the  winter  months  that  the  properties  of  these 
climates,  which  are  regarded  as  remedial  in  phthisis,  are 
especially  manifested.  These  properties  are :  (i)  low  atmo- 
spheric pressure,  some  five  inches  of  mercury  below  the 
barometric  measurement  at  the  sea-level;  (2)  dryness  of  atmo- 
sphere; (3)  purity  of  air,  as  shown  by  freedom  from  organic 
and  inorganic  dust;  (4)  aseptic  qualities  by  virtue  of  freedom 
from  org'anic  germs  and  the  relatively  large  proportion  of 
ozone  present;  (5)  low  temperature  of  the  air;  (6)  increased 
transparency  to  the  sun's  rays,  both  illuminating  and  chemical 
(diaphaneity  and  diathermancy),  from  the  thinness  and  clear- 
ness of  the  atmosphere  and  the  diminished  amount  of  aqueous 
vapour  contained  therein;  (7)  stillness  of  the  air,  in  conse- 
quence of  which  its  coldness  is  less  felt.  In  the  meteorologi- 
cal table  on  p.  643  certain  of  these  factors  are  demonstrated. 

The  beneficial  effects  of  these  climates  are  attributable  to 
the  rarefaction  of  the  air  as  a  stimulant  to  the  respiratory 
function;  to  its  aseptic  qualities,  by  virtue  of  which  putrefac- 
tive and  fermentative  processes  are  hindered;  and  to  the  vivi- 
fying influence  of  the  brilliant  and  warm  sunshine,  which 
enables  patients  to  be  much  out  of  doors.  One  effect  of  the 
climate  is  seen  in  the  blood-count,  which  normally  at  Davos 
registers  six  milHon  red  cells,  with  a  percentage  of  haemo- 
globin ranging  to  105  per  cent,  or  even  higher. 

The  diaphaneity  and  diathermancy  of  the  rarefied  atmo- 
sphere of  these  high  regions  is  an  important  fact,  to  which 
Dr.  Denison  and  Sir  Hermann  Weber^  were  among  the  first 
to  draw  attention.  By  virtue  of  this  quaUty,  due  especially 
to  the  smaller  amount  of  aqueous  vapour  present  in  the  atmo- 
sphere, the  rays  of  the  sun  pass  throug-h  with  increased  readi- 
ness, powerfully  affecting  objects  exposed  to  them,  although 
heating  the  air  itself  but  little  during  their  passage.  Dr. 
Denison^  put  the  matter  shortly  by  giving  the  following  rule 
of  increasing  diathermancy  of  air,  viz. :  "  For  each  1,000  feet 
rise  in  elevation  there  are  about  four  degrees  greater  differ- 
ence between  the  temperatures  in  the  sun  and  in  the  shade  on 
perfectly  clear  days  at  2  p.m.,  as  recorded  by  the  black 
metallic-backed  thermometers,  other  influences  than  those  of 


ON   CLIMATIC   CHANGE  639 

sun  and  shade  being  excluded."  Sir  James  Dewar  has  shown 
tlie  intensely  destructive  power  of  the  ultra-violet  rays  upon 
morbific  organisms,  and  these  rays  are  in  the  higher  alti- 
tudes more  potent  because  less  obstructed. 

Improved  sanguification  and  nutrition,  expansion  of  un- 
affected parts  of  the  lungs,  and  restriction  of  the  limits  of 
diseased  areas,  are  results  obtained  in  a  striking  degree  in 
successful  cases  by  residence  in  these  locahties.  They  are, 
however,  rigorous  climates,  and  it  must  not  be  forgotten  that, 
potent  for  good  in  well-chosen  cases,  they  are  also  active  in 
working  mischief  to  those  whose  condition  is  not  well  adapted 
for  them.  It  cannot,  moreover,  now  be  claimed,  as  was  once 
asserted,  that  these  climates  possess  any  exclusive  power,  by 
virtue  of  rarefaction  of  atmosphere,  of  developing  healthy 
lung  and  contracting  diseased  areas.  We  have  known  patients 
recover  under  the  most  diverse  climatic  conditions,  and  have 
often  observed  the  development  of  unaffected  lung  proceed  to 
the  utmost  possible  limits  in  patients  who  have  never  been 
at  a  higher  level  than  the  galleries  of  the  Brompton  Hospital. 
Such  patients  have  found  their  own  salvation  in  acquired 
immunity.  The  physical  state  common  to  all  such  cases  is 
contraction  of  the  hmits  of  disease,  and  compensatory  en- 
largement of  the  opposite  and  of  the  free  portions  of  the  same 
lung,  and  we  doubt  the  possibihty  of  exceeding  the  compen- 
satory development  that  may  be  observed  in  these  favourable 
cases  of  phthisis  arrested  in  the  plains.  Nevertheless,  the 
statistics  of  Dr.  Theodore  Williams,*  the  results  of  treatment 
in  the  Swiss  sanatoria,^  and  our  own  experience  would  sanc- 
tion the  view  that  in  suitable  cases  these  good  results  may  be 
best  obtained  by  high-altitude  treatment,  and  we  are  only  now 
desirous  of  pointing  out  that  rarity  of  atmosphere,  although 
it  may  be  an  auxiliary,  is  by  no  means  an  essential  condition 
for  bringing  about  this  much  desired  end.  We  have  else- 
where emphasised  the  importance  of  distinguishing  between 
merely  enlarged  or  dilated  lung  and  truly  hypertrophied  lung, 
in  association  with  localised  or  arrested  disease  of  some  other 
portion.  There  is  no  advantage,  but  much  the  contrary,  in 
producing  emphysema  in  phthisis. 

The  cases  suitable  for  treatment  at  elevated  resorts  are 
those  of  threatened  disease  and.  locaHsed  tuberculosis  in  the 
early  and  the  quiescent  stage,  especially  when  associated  with 


640  DISEASES   OF  THE  LUNGS   AND   PLEURA 

a  languid  temperament  and  a  moderate  degree  of  anaemia. 
Cases  of  hereditary  tendency,  defective  thoracic  conformation 
and  capacity,  incomplete  recovery  from  acute  or  subacute 
inflammatory  affections  of  the  chest,  whether  pleuritic  or 
parenchymatous,  are  pecuHarly  adapted  for  such  treatment. 
Cases  of  more  advanced  tuberculous  disease,  if  it  be  restricted 
and  inactive,  are  also  suitable,  provided  that  the  patient  have 
sufficient  vitality  to  respond  to  the  extra  demand  made  upon 
his  system  by  the  rigorous  climate.  It  is  important  that  the 
reserve  lung  be  sound,  not  emphysematous,  and  that  the 
heart  and  vessels  be  healthy. 

Cases  which  have  commenced  with  hemoptysis,  and  in  the 
course  of  which  haemoptysis  has  from  time  to  time  occurred 
from  active  or  passive  congestions,  are  not  thereby  disquali- 
fied for  residence  in  high  climates,  but  a  few  weeks  should 
elapse  before  removal  there.  For  cases  of  recurrent  haemor- 
rhage, however,  in  which  an  ectasia  or  aneurism  of  a  pul- 
monary vessel  in  a  localised  cavity  is  suspected,  such  climates 
should  not  be  suggested.  The  following  conditions  are  also 
unsuitable  for  residence  in  high  altitudes— viz.,  the  acute  stage 
of  phthisis  in  any  form;  the  erethic*  constitution  in  any  stage 
of  the  disease;  cases  in  which  the  larynx  is  affected;  patients 
with  advanced  phthisis;  those  in  whom  the  tuberculous 
disease  is  complicated  by  marked  emphysema,  albuminuria,  or 
intestinal  ulceration,  or  associated  with  signs  of  general  bron- 
chial irritation;  those  in  whom  the  malady  makes  its  appear- 
ance in  later  life. 

The  winter  season  is  the  best  to  choose  for  residence  in 
these  localities,  but  in  those  cases  in  which  benefit  is  experi- 
enced, continued  residence  through  the  summer  at  about  the 
same  elevation,  and  a  second  winter  in  the  same  locaHty, 
should  be  decidedly  advised.  A  third  or  fourth  year  may 
sometimes  be  thus  well  spent.  In  cases  of  mere  delicacy  or 
threatened  disease  during  convalescence  from  some  acute 
chest  malady,  a  single  short  period  of  residence  may  suffice. 
In  early-stage  cases,  which  have  derived  benefit  from  a  single 
winter,  the  good  result  is  often  maintained  by  two  or  three 
months'  return  to  the  same  locality  for  several  succeeding 
winters.     In  this  practical  world  but  few  people  can  afford 

*  Nervous,   irritable  subjects,   neuralgic,   dyspeptic,   bad  sleepers,   with 
habitually  quick  pulse  and  dry,  harsh  skins. 


ON  CLIMATIC   CHANGE  64 1 

to  live  indefinitely  in  idleness  above  the  clouds !  Persons 
who  have  recovered  after  a  season  or  two  at  the  Alpine  sta- 
tions may  sometimes  live  and  earn  a  living  in  the  highlands 
of  South  Africa,  to  which  we  shall  refer  later. 

Patients  should  as  a  rule  proceed  to  their  proposed  winter- 
quarters  on  high  ground  not  later  than  the  end  of  October,  so 
that  they  may  avoid  the  dampness  and  fogs  which  at  this 
season  of  the  year  are  so  characteristic  of  our  English  climate. 
They  should  not  return  home  before  the  commencement  of 
May,  the  winds  in  England  during  April  often  proving  very 
trying".  It  is  a  not  uncommon  practice  for  patients  to  leave 
the  high  Alpine  resorts  in  March,  when  the  snow  is  melting, 
and  to  stay  at  some  lower  level,  such  as  Thusis,  Pronwn- 
togno,  Ragatz,  or  Glion,  before  returning  home.  But  such 
a  practice  is  not  essential.  It  is  most  important  to  warn 
patients  against  wandering  about  in  a  restless  fashion,  visit- 
ing other  European  stations  at  the  end  of  their  treatment  in 
high  altitudes.  Our  experience  is  that  such  cases  often  suffer 
relapse,  and  return  in  much  the  same  condition  as  that  in 
which  they  left  home. 

Surgical  Tuberculosis.— The  benefits  to  be  derived  from  a 
residence  in  Alpine  stations  are  not  confined  to  cases  of  pul- 
monary tuberculosis,  and,  as  Rollier''^  and  others  have  shown, 
remarkable  results  are  obtained  at  Leysin  (4,800  feet)  in  sur- 
gical tuberculosis,  including  affections  of  the  bones,  joints, 
spine  and  glands,  and  also  such  manifestations  as  tuberculous 
peritonitis  and  disease  of  the  genito-urinary  tract.  In  such 
cases,  in  addition  to  the  general  climatic  influence,  direct 
treatment  is  carried  out  by  gradually  exposing  the  whole 
body,  as  well  as  the  part  affected,  to  the  immediate  action  of 
the  sun's  rays  for  increasing  periods  of  time,  and  to  this  form 
of  treatment  the  name  "Heliotherapy"  has  been  appHed. 

The  Rocky  Mountains. — Among-  the  elevated  resorts  in 
North  America  may  be  especially  mentioned  the  Rocky  Moun- 
tain stations,  Colorado  Springs  and  Denver,  situated  in 
Colorado  State  at  an  elevation  of  between  5,000  and  6,000  feet. 
Three  miles  from  Colorado  Springs,  and  facing  Pike's  Peak, 
the  Cragmor  Sanatorium  has  been  built  at  an  elevation  of 
6,100  feet.  The  climate  of  this  region  resembles  in  many 
respects  that  of  the  Swiss  resorts,  but,  as  may  be  seen  by  a 
study  of  the  meteorological  data  (p.  643),  it  is  several  degrees 

41 


642  DISEASES   OF  THE  LUNGS   AND   PLEURA 

warmer  in  winter,  the  mean  temperature  for  the  six  months 
at  Denver  being  36-5°  F.,  as  compared  with  27'2°  F.  at  Arosa, 
and  25'9°  F.  at  Davos.  Snow,  consequently,  is  not  often  seen. 
A  much  gTeater  amount  of  sunshine  is  also  enjoyed,  but 
against  this  must  be  set  the  fact  that  the  region  is  decidedly 
more  windy,  and  dust-storms,  often  of  a  peculiarly  irritating 
character,  are  not  infrequently  met  with. 

Other  stations  in  the  Rocky  Mountains  are  Oracle 
(4,500  feet)  in  Arizona,  and  Santa  Fe  (7,000  feet)  and  Las 
Vegas  (6,400  feet)  in  New  Mexico.  Manitou  Park  (7,500  feet) 
and  Estes  Park  (6,800  feet),  in  Colorado,  are  also  favourite 
summer  resorts.^ 

South  American  Andes. — At  Jauja,  Tarma,  Huancayo,  in 
the  Peruvian  Andes,  at  Santa  Fe  de  Bogota,  and  at  Quito,  in 
Ecuador,  not  far  from  the  equator,  all  at  an  elevation  of  about 
10,000  feet,  the  effects  of  a  highly  rarefied  air  are  obtained 
with  a  temperate,  equable  and  brilliant  climate.^  Only  in  rare 
instances,  however,  would  one  suggest  such  elevations  for 
invalids. 

The    South   African   Highlands. — These  highlands   possess 
climates  of  the  greatest  value  for  the  sufferer  from  tubercu- 
losis, though  at  the  present  time  such  cases  are  not  welcomed 
in  the  Union.     The  benefits  of  the  climate  may,  however,  be 
enjoyed  by  those  who  have  merely  an  inherited  tendency  to 
the  affection,  and  such  patients  may  here  develope  into  robust 
health,  the  dry,  warm  summer  and  temperate  winter  climates, 
which   these   high   upland   reg'ions   possess,    rendering   them 
suitable  for  permanent  residence,  more  especially  for  those 
who  desire  to  escape  our  cold  winters.     Before  recommending 
South  Africa  for  prolonged  residence,  we  should  remember 
that  the  ordinary  necessaries  of  life  in  that  country  are  expen- 
sive, and  that  employment  may  not  be  easy  to  obtain.   Unless, 
therefore,  a  patient  possesses  private  means,  or  has  friends  in 
the  country,  or  some  definite  work  in  view,  we  may  well  hesi- 
tate before  suggesting  a  residence  there,  however  suitable  on 
other  grounds  the   case   may   seem.     It  is,   perhaps,   hardly 
necessary  to  add  that  it  is  absolute  folly  for  those  in  active 
or  advanced   consumption   to   think   of   venturing   upon   the 
fatigues  and  risks   of  so   long  a  journey,   and  it  would  be 
exceedingly  improper  to  advise  them  to  do  so,  even  were  it 
probable  that  they  would  be  permitted  to  land.     Private  sana- 


ON  CLIMATIC  CHANGE 


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644  DISEASES  OF  THE  LUNGS   AND  PLEURAE 

toria  exist  at  Modderfontein  near  Johannesburg",  and  at  Bel- 
fast^ both  in  the  Transvaal;  at  N ottingham  Road,  a  healthy 
farming  district  in  Natal,  forty  miles  from  Maritzburg;  at 
Laingsburg,  in  the  Cape  Province,  and  no  doubt  in  other  places. 

The  South  African  resorts  may  be  classified  into  those  of 
the  Cape,  Natal,  the  Orange  Free  State,  and  the  Transvaal 
Provinces.  There  are  many  localities,  and  will,  no  doubt,  in 
the  future  be  many  more,  available  for  the  sojourn  or  settle- 
ment of  those  who  cannot  enjoy  full  health  in  their  own 
country,  yet  who  are  not  in  any  actual  or  active  degree  of 
pulmonary  unsoundness.  We  can  only  here  refer  to  a  few 
places  which  are  of  ready  access,  and  are  suitably  equipped 
for  the  accommodation  of  the  degree  and  kind  of  invalidism 
which  we  have  in  mind. 

The  ProYince  of  the  Cape  of  Good  Hope. — Cape  Town  itself, 
seventeen  days'  voyage  from  Southampton,  is  entirely  un- 
suited  for  chest  invalids.  As  pointed  out  by  Mr.  Samler 
Brown,*  in  his  interesting  and  valuable  guide  to  South  Africa, 
it  is,  owing  to  its  western  aspect,  swept  by  the  cold  Antarctic 
current,  and  the  climate  is  consequently  cold,  windy  and 
treacherous,  although  the  mean  annual  temperature  is  about 
the  same  as  that  of  Naples.  It  will,  of  course,  be  remembered 
that  the  summer  months  of  South  Africa  are  from  November 
to  May,  when  the  autumnal  rains  begin.  Simons  Town,  on 
Simons  Bay,  is  the  first  southern  station  we  need  mention, 
and  although  only  twenty  miles  from  Cape  Town,  it  is  washed 
by  a  sea  current  from  the  Indian  Ocean  from  io°  to  12° 
warmer  than  that  which  bathes  the  western  shores,  including 
Table  Bay.  With  a  mean  maximum  annual  temperature  of 
70*4°  and  minimum  of  57' 1°,  and  a  rainfall  of  29-3  inches,  it 
forms  a  good  resting-place,  and  also  one  in  which  certain 
deHcate  patients  may  reside  throughout  the  year.  South- 
eastern winds  are  somewhat  of  a  drawback  during  the  sum- 
mer months,  and  during  their  prevalence  protection  can  be 
sought  by  a  change  to  Wynberg,  a  healthy  suburb  eight  miles 
from  Cape  Town,  which  is  protected  from  these  winds  by  the 
shoulder  of  Table  Mountain. 

The  highland  districts  of  the  Cape  Province  are,  however, 
more  desirable  for  chest  invalids,  and  the  Cape  to  Cairo  Rail- 
way, which  runs  north-east  to  the  western  border  of  the 
Orange  Free  State  and  the  Transvaal,  skirts  the  great  Karroo 


ON   CLIMATIC   CHANGE  645 

tableland  at  an  elevation  of  3,000  to  4,000  feet,  and  along  or 
within  easy  reach  of  its  route  are  several  places  of  varying 
altitude  which  may  be  recommended.  The  high-ground 
climates  of  South  Africa,  the  stations  of  which  we  are  about 
to  consider,  possess,  like  other  elevated  regions,  a  low  atmo- 
spheric pressure,  abundant  sunshine  with  great  diaphaneity 
and  diathermancy  of  the  atmosphere,  and  are  further  remark- 
able for  dryness,  the  rain  falling  principally  in  storms,  chiefly 
in  the  autumn  (our  spring").  Owing  to  their  geographical 
position,  they  are  very  much  warmer  than  the  Swiss  moun- 
tain resorts;  but  they  are  also  more  dusty  and  windy. 

Ceres  (1,493  feet),  eighty-four  miles  from  the  Cape,  a 
small,  well-laid-out  town,  with  g'ood  water-supply,  possesses  a 
warm,  dry  summer  climate  (corresponding  with  our  winter), 
with  a  mean  shade  temperature  of  66'5°,  a  sandy  soil,  abun- 
dant sunlig'ht,  and  cool  nights,  with  but  little  mist;  it  is,  more- 
over, sheltered  from  prevailing  winds.  The  rainfall,  41  inches, 
occurs  mainly  in  the  winter,  the  mean  temperature  of  which  is 

517°. 

Beaufort  West  (2,850  feet),  some  150  miles  farther  on,  is 
also  a  well-found  town,  but  with  more  arid  and  less  pic- 
turesque surroundings. 

Graaf  Reinet  (2,463  feet),  more  central  in  the  Province,  can 
be  reached  through  the  De  Aar  Junction,  but  is  more  acces- 
sible direct  from  Port  EHzabeth,  from  which  it  is  distant  185 
miles.  It  is  a  well-found  townlet  of  some  7,000  inhabitants, 
possessing-  a  warm,  dry,  brig-ht  and  sunny  cHmate,  with  well- 
laid-out  botanical  gardens,  sporting*  clubs,  sheep  and  ostrich 
farms,  hom.-e-irrigated  land,  forming  "  a  veritable  oasis  in  the 
dry  Karroo  Veld."^  The  mean  summer  temperature  (Novem- 
ber to  April)  is  697°,  that  of  winter  (May  to  October)  57°; 
the  total  rainfall  17"  15  inches  in  fifty-six  rainy  days.  Somerset 
East  (2,400  feet)  is  another  and  smaller  agricultural  town, 
with  similar  features  to  Graaf  Reinet,  picturesque  surround- 
ings and  excellent  climate.  Middlehurg  (4,095  feet),  250  miles 
from  Port  EHzabeth,  similarly  situated  amid  mountain  and 
river,  is  an  agricultural  centre  with  a  more  stormy  summer 
and  a  colder  winter,  possessing  attractions  for  more  robust 
persons. 

Aliwal  North  (4,350  feet),  in  the  north-east  corner  of  the 
Province,  situated  on  the  Orange  River,  and  bordering  the 


646  DISEASES   OF  THE  LUNGS   AND   PLEUR.^ 

Orange  Free  State  Province,  is  one  of  the  choice  spots  for 
residence.  It  is  best  approached  by  rail  from  East  London 
(282  miles),  and  is  in  direct  communication  with  the  Orange 
Province  by  a  bridge  across  the  river.  Aliwal  North  is  a  fine 
well-equipped  town,  with  churches,  schools,  and  good  recrea- 
tion-gTOunds,  in  a  well-watered,  fertile  neighbourhood,  with 
outlying  centres  of  agriculture  within  easy  reach  by  post-cart 
or  light  railway.  The  summer  climate,  with  a  mean  tempera- 
ture of  65-9°,  is  tempered  by  a  somewhat  larger  rainfall  than 
the  other  places  named,  whilst  the  winter  is  bright  and  dry, 
with  bracing  air  and  cold  nights;  mean  temperature,  5i"2°, 
The  extremes  of  shade  temperature  recorded  are  93'7°  maxi- 
mum and  I9'2°  minimum.  Near  the  town  are  warm  sulphur 
springs,  with  a  good  bathing  establishment.  In  this  town 
and  its  surroundings  are  thus  to  be  found  excellent  residen- 
tial conditions  for  the  health-seeker  of  the  class  which  we 
have  in  view.  Eighty  miles  to  the  south-west  lies  Barkly 
East  (5,831  feet),  the  highest  town  in  the  Cape  Province,  in 
the  midst  of  a  healthy  mountainous  district,  with  excellent 
pasturage. 

Kiniberley,  farther  north,  on  the  western  border  of  the 
Orange  Free  State  Province,  and  at  an  elevation  of  4,042  feet, 
is  on  the  main  line  from  the  Cape,  from  which  it  is  distant 
about  650  miles.  It  is  a  large  town  of  about  50,000  inhabi- 
tants, 12,000  of  them  Europeans,  with  the  usual  public  build- 
ings, club,  library,  theatre,  park  and  gardens.  There  is  also 
a  large  hospital  or  sanatorium,  built  by  the  late  Mr.  Cecil 
Rhodes  and  the  De  Beers  Company,  and  a  model  village  for 
the  employes  of  the  diamond-mines,  the  chief  industry  of  the 
place.  With  a  mean  summer  temperature  of  73'9°,  and  winter 
58'6°,  extremes  of  shade  temperature  107°  and  27-6°,  and  a 
rainfall  of  i8'26  inches  almost  entirely  in  summer,  Kimberley 
is,  generally  speaking,  a  warm,  bracing  climate,  particularly 
dry,  bright,  and  bracing  in  the  winter.  The  town  itself  would 
not  be  ideal  for  a  chest  invalid,  especially  if  of  the  erethic 
type;  but  suburban  parts  within  easy  access  of  the  town  could 
be  found  fairly  suitable  for  those  who  had  business  there. 

Natal. — Facing  the  Southern  Indian  Ocean,  this  Province 
possesses  a  moister  and  a  somewhat  warmer  climate  than 
either  the  Cape  or  the  Orange  Free  State  Province,  having 
broadly  speaking,  twice  the  rainfall  of  the  latter.     On  the 


ON  CLIMATIC   CHANGE  647 

whole,  the  locaUties  within  it  are  adapted  for  a  less  robust 
type  of  invalid,  and  for  those  whose  mucous  membranes — 
whether  abdominal  or  thoracic — are  irritable.  Durban  is  the 
port  of  entrance,  and  is  a  fairly  healthy,  warm  district.  Pieter- 
maritsburg,  generally  spoken  of  as  Maritzburg,  containing  in 
1918  a  white  population  of  18,527,  is  within  seventy  miles  of 
Durban,  and  is  the  capital  of  Natal.  Situated  at  an  elevation 
of  2,225  f'Set  above  the  sea,  it  is  a  well-found  town,  with 
library,  schools,  hospital,  pubHc  gardens,  and  all  the  appurten- 
ances of  a  capital.  The  mean  summer  temperature  is  6g-6°; 
winter,  6o'i°;  rainfall,  38  inches,  mainly  in  the  summer,  when 
there  are  heavy  storms,  the  winter  months,  except  September 
and  October  (corresponding  with  our  March  and  April),  being 
fairly  dry.  Maritzburg  is  a  healthy  enough  locality  for  those 
whose  affairs  keep  them  there,  but  it  is  somewhat  relaxing, 
being'  surrounded  by  hills.  For  many  people  with  a  disposi- 
tion to  bronchial  ailments  it  might  be  suitable.  The  sur- 
roundings are  picturesque  and  beautiful,  and  there  are  many 
localities  in  its  neighbourhood,  such  as  Greytown,  suitable  for 
residence. 

Estcourt  (3,833  feet),  another  seventy  miles  farther  on  from 
Durban,  is  a  small  agricultural  town  finely  situated  amidst 
grazing  and  stock-breeding  country.  It  has  a  fine,  fairly  dry- 
Natal  climate,  free  from  dust,  and  would  seem  to  be  well 
adapted  for  a  country  farming  life.  The  little  town  is  an  im- 
portant junction  for  railway-lines  leading  to  Weenan,  Tugela, 
and  Harrismith  from  the  main  line  to  Johannesburg. 

The  Orange  Free  State  Province. — This  comprises  the 
highest  tableland  of  Southern  Africa,  having  a  mean  altitude 
between  4,000  and  5,000  feet.  Bloemfontein,  Harrismith  and 
Ladybrand  may  be  referred  to  as  districts  within  its  borders 
of  special  importance  from  a  climatic  point  of  view. 

Bloemfontein,  100  miles  due  east  of  Kimberley,  can  be 
reached  by  rail  from  that  town  or  from  Port  Elizabeth,  the 
nearest  route  from  the  coast,  or  from  East  London  or  Dur- 
ban. The  town  is  situated  on  a  plateau  (4,500  feet),  with  low 
hills  to  the  north-east  and  south,  and  has  a  population  of 
some  34,000  inhabitants,  nearly  15,000  of  whom  are  white.  It 
is  a  larg-e  pleasant  town,  more  of  a  garden  city  than  either 
Kimberley,  Maritzburg  or  Johannesburg,  and  is  provided  in 
a,n  ample  degree  with  the  usual  municipal,  educational  and 


648  DISEASES   OF   THE  LUNGS   AND   PLEURA 

racreatory  advantages.  Possessed  of  an  admirable  climate, 
Bloemfontein  has  long  been  recognised  as  a  health  resort  for 
the  delicate-chested,  its  usefulness  in  this  respect  only  being 
impaired  by  its  commercial  success  and  extension.  As  an  all- 
year-round  place  of  residence,  it  is  perhaps  one  of  the  choicest 
of  this  favoured  Province;  and  there  are  smaller  centres  of 
civilisation  within  reach,  such  as  Boshof,  eighty  miles  distant, 
Mfhere  the  climate  is  practically  the  same,  v^ith  more  imme- 
diate country  conditions.  The  district  is  pastoral,  agriculture 
and  cattle-breeding  being  the  main  industries.  The  mean 
summer  temperature  is  68'9°;  winter,  54"0°;  extremes,  94*7° 
and  20'6°  respectively;  rainfall,  23-07  inches,  distributed  over 
fifty-eight  days,  forty-four  of  which  occur  in  the  summer 
months.*"  A  marked  fall  of  temperature  takes  place  at  night 
in  this,  as  in  all  the  bright,  dry  South  African  cHmates.  This 
nightly  fall  is  beneficial  to  health,  provided  it  be  duly  reck- 
oned for. 

Sixty  miles  due  east  of  Bloemfontein,  on  the  Durban- 
Bloemfontein  line,  is  the  station  of  Westminster.  The 
country  around  is  devoted  to  agriculture,  and  divided  into 
farms  belonging  to  Enghsh  settlers,  and  on  these  farms  we 
have  known  several  patients  do  well  in  this  splendid  climate. 
The  following  extract  from  a  letter  written  in  July,  1913, 
from  a  former  patient  will  be  of  interest : 

"  We  are  here  at  an  altitude  of  5,500  feet.  What  rain  we  have 
(on  an  average  24  inches  a  year)  falls  from  the  middle  of  September 
to  the  end  of  February,  and  mostly  comes  in  heavy  storms  or 
showers  of  an  inch  at  a  time.  Almost  every  day,  therefore,  there  is 
a  clear  blue  sky  and  sunshine  from  dawn  to  dusk.  In  the  winter 
we  have  no  rain,  and  have  had  none  now  since  April.  The  days 
in  winter  are  warm,  the  nights  bright,  crisp,  and  frosty.  It  is  pos- 
sible to  go  about  in  shirt -sleeves  all  day  long  in  winter,  and  sleep  out 
at  night.  The  temperature  falls  to  about  15°  of  frost  in  the  winter, 
and  I'ises  to  about  90°  in  the  shade  in  summer.  Voluntarily  or  not, 
it  is  almost  impossible  for  life  out  here  to  be  anything  but  an  open-air 
one,  and  on  account  of  the  lovely  climate  it  is  rare  to  see  a  window  or 
door  shut.  A  large  number  of  the  residents,  even  when  sound,  sleep 
out  on  the  stoep  (verandah),  which  surrounds  every  house,  all  houses 
here  being  built  like  bungalows,  on  the  ground  floor  only." 

About  thirty  miles  farther  east  of  Westminster,  on  the 
Basutoland  border  of  the  Province,  is  the  small  town  of 
Lady  brand,  in  the  midst  of  an  agricultural  district,  with  a  not 


ON  CLIMATIC   CHANGE  649 

very  distant  view  of  the  Malttti  Mountains  of  Basuto.  "  A 
superb  climate  in  winter,  especially  May  to  August,  and  not 
too  hot  in  summer,  as  there  is  usually  a  slight  breeze  from 
the  Malutis "  (extract  from  letter  of  patient — Rev.  George 
Johnson).  The  little  town  of  Bethlehem  (5,300  feet),  between 
Ladybrand  and  Harrismith,  on  sandstone  formation,  is  also 
well  adapted  for  reconstituting'  the  pulmonaiy  invalid. 

Harrismith,  250  miles  from  Durban,  the  nearest  port,  and 
130  miles  north-east  from  Ladybrand  on  the  Kimberley-Dur- 
ban  line,  is  a  sunny,  bracing  mountain  district  (5,250  feet), 
having  the  Drakenburg-  range  of  mountains  thirty  to  fifty 
miles  south  and  east.  The  district  is  grazing-  and  agricultural. 
Between  Ladybrand  and  Harrismith,  on  the  western  side  of 
the  Maluti  Mountains,  lies  a  rich  cereal-farming  stretch  of 
country,  extending-  for  100  miles,  known  as  the  "  Conquered 
Territory."^  The  healthy  townlet  of  Picks  is  about  half-way 
on  the  line  of  railway,  to  the  south-east  of  which  the  fertile 
country  is  situated.  Harrismith  has  all  the  characteristics  of 
a  mountain  climate  in  the  warmer  latitudes,  with  its  bright 
and  brilliant  days,  always  to  be  followed  by  cool,  and  often 
very  cold,  nights.  It  is  a  climate  admirably  fitted  for  persons 
intrinsically  sound,  yet  with  perhaps  a  strain  of  pulmonary 
weakness  in  their  ancestral  line. 

The  Transvaal  ProYince. — The  climate  of  the  Transvaal, 
which  in  its  southern  portion  ranges  at  much  the  same  level 
as  the  Orange  River  Province,  with  which  it  is  continuous, 
is  drier,  more  dusty,  more  disturbed  by  storms,  and  with 
greater  changes  of  temperature  than  that  of  its  southern 
neighbour.  The  country  is  for  the  most  part  sandy  and  dry, 
with  subjacent  and  extruding  granite  rocks.  Large  districts 
are  desiccated  in  the  summer,  and  violent  dust-storms  are 
prevalent.  The  summer  heat  is  considerable,  although  the 
nights  are  cool.  The  winters  are  cold  and  bracing.  The 
Province  has  generally  been  decried  for  all  people  with  pul- 
monary delicacy  or  unsoundness,  and  yet  we  have  witnessed 
some  very  striking  examples  of  benefit  derived  from  a  resi- 
dence in  Johannesburg  prior  to  the  period  of  the  war. 

Johannesburg  (5,764  feet)  is  a  city  of  260,000  inhabitants, 
rather  more  than  half  of  them  whites,  supplied  with  all  the 
luxuries  of  a  modern  capital,  if  the  price  can  be  paid  for  them. 
It  is  easy  of  access  from  the  Cape,  from  which  it  is  distant 


650  DISEASES   OF   THE  LUNGS   AND   PLEURA 

957  miles  on  the  main  line.  Durban  is  the  nearer  port,  483 
miles  via  Kroonstadt,  and  it  can  be  reached  by  a  still  shorter 
railway  journey  from  Delagoa  Bay  via  Pretoria.  Invalids 
were  formerly  warned  away  from  Johannesburg,  chiefly  on 
account  of  the  dust-storms  which  prevail  from  time  to  time. 
It  is,  moreover,  an  exciting  mental  atmosphere,  with  stock- 
broking  and  mining  industries,  wanting  in  the  restful  con- 
ditions proper  to  a  health  resort.  Still,  there  are  some  who 
cannot  endure  a  pastoral  hfe,  who  are  inured  to  business,  and 
can  neither  live  nor  make  a  living  without  rubbing  shoulders 
and  clashing  intellects  with  their  fellow-men,  and  amongst 
such  we  have  in  some  cases  recommended  Johannesburg  with 
great  advantage,  advising,  however,  a  suburban  residence. 
The  size  of  the  town  has  much  extended  of  late  years,  and  its 
sanitation  has  been  greatly  improved,  and  is  now  carefully 
supervised  by  able  sanitary  officers,  who  by  appropriate 
measures  have  diminished  the  dust  nuisance.  The  water- 
supply  is  excellent. 

The  subtropical  climate  of  Rhodesia  is  not  to  be  recom- 
mended for  invalids,  although  Buluwayo  and  Salisbury  are  by 
no  means  unhealthy  places  for  those  who  seek  farming  and 
mining  pursuits  and  the  sport  to  be  had  in  such  localities. 
Indeed,  the  late  Mr.  Selous,'"  in  his  interesting  book,  spoke 
many  years  ago  of  the  open  grassy  downs  of  Mashonaland 
as  possessed  of  a  dehghtful  cHmate  for  the  greater  part  of  the 
year — "a  country  where  European  children  would  grow  up 
with  rosy  cheeks."  The  plateau  (4,000  to  6,000  feet  elevation) 
was  at  one  time  thickly  inhabited  by  a  peaceful  and  a  pastoral 
people. 

The  Argentine. — For  those  who  have  South  American  con- 
nections we  may  draw  attention  to  the  La  Cumbre  district  in 
the  Argentine  as  one  in  which  we  have  known  consumptives 
.to  do  well.  This  district  is  a  high  tableland,  some  4,000  feet 
in  altitude.  Situated  in  the  hills  of  Cordoba,  the  mean  sum- 
mer temperature  is  70°  to  80°,  that  of  winter  40°  to  60°. 
The  soil  is  rich,  the  air  exhilarating,  and  there  is  abundant  sun- 
shine. La  Cumbre  itself  is  a  small  English  colony,  and  it  is 
often  possible  to  obtain  there  suitable  employment.^^ 

The  Hill-Stations  of  India. — These  are  by  no  means  equal 
to  the  others  mentioned  for  the  treatment  of  phthisical  cases. 
The  best  known  is  Darjeeling^  situated,  at  an.  altitude  of  about 


ON  CLIMATIC   CHANGE  65 1 

7,000  feet,  among  the  southern  slopes  of  the  Himalayas.  The 
rainfall  is,  however,  132  inches — very  different  from  the 
figures  recorded  at  the  other  high-altitude  stations  which  we 
have  been  considering — and  during  the  rainy  season  it  is 
accordingly  very  damp.  A  sanatorium  has  recently  been  built 
in  the  Kumaon  Hills  at  Lotni,  Bhowali,  not  far  from  Naini 
Tal,  the  summer  capital  of  the  United  Provinces. 

Stations  of  Medium  Elevation  (1,000-3,000  Feet). — 
Among  places  of  lower  elevation,  we  may  mention  Gorbers- 
dorf,  in  Silesia  (1,800  feet);  Falkenstein  (1,600  feet)  and  its 
neig"hbourhood,  in  the  Taunus  Range,  not  far  from  Wies- 
baden; Nordrach  (1,475  feet),  Badenweiler  (1,450  feet),  and 
St.  Blasien  (2,530  feet),  all  in  the  Black  Forest;  Lausanne 
(1,690  feet);  Glion  (2,270  feet);  and  Meran  (1,000  feet),  in  the 
Austrian  Tyrol.  At  the  first  two  of  these,  Gorbersdorf  and 
Falkenstein,  are  the  well-known  sanatoria  inseparably  con- 
nected with  the  names  of  their  founders,  Dr.  Brehmer  and 
Dr.  Dettweiler,  who  did  so  much  to  introduce  the  open-air 
treatment  of  consumption,  though  the  institution  at  Falken- 
stein is  no  longer  used  for  the  treatment  of  tuberculosis.  In 
these  stations  of  medium  elevation,  to  which  we  might  add 
others  in  the  Hars  Mountains,  the  element  of  a  rarefied  atmo- 
sphere is  wanting-,  but  the  air  is  clear,  dry  and  bracing,  and  is 
adapted  for  certain  cases  for  which  the  higher  resorts  are 
unsuited.  At  Meran  the  "grape  cure"  is  conducted  in  the 
autumn  (see  p.  604),  the  "  koumiss  cure  "  in  the  spring,  and 
baths  and  inhalations  all  the  year  round. 

It  is  only  by  weighing  all  the  circumstances  of  each  indi- 
vidual case  that  it  can  be  decided  whether  on  the  whole  a 
better  result  may  be  hoped  for  by  a  sojourn  at  the  higher  or 
the  lower  stations,  and  an  accurate  diagnosis  of  the  physical 
condition  of  the  patient  must  ever  be  the  first  step  towards 
the  solution  of  the  problem. 


REFERENCES. 

^  For  a  more  detailed  description  of  these  places  and  of  the  numerous 
Swiss  summer  resorts  of  high  altitude,  the  reader  should  refer  to — 

(i)  Climatotherafy  and  Balneotherapy,  by  Sir  Hermann  Weber,  M.D., 

and  F.  Parkes  Weber,  M.D.     London,  1907. 
(2)  A  Handbook  of  Climatic  Treatment,  by  William  R.  Huggard,  M.D. 
London,   1906. 


652  DISEASES   OF   THE  LUNGS    AND   PLEURA 

^  Croonian  Lectures  on  the  Hygienic  and  Climatic  Treatment  of  Chronic 
Pulmonary  Phthisis,  by  Hermann  Weber,  M.D.,  p.  84.     London,  1885. 

^  (i)  The  Rocky  Mountain  Health  Resorts,  by  Charles  Denison,   M.D., 
p.  68.     Boston,  1881. 
(2)    Analysis    of   Atmospheric    Humidities    in    the    United    States,    by 
Charles  Denison,  M.D.,  p.  19.     Chicago,   1884. 

■*  "  What  Influence  has  Climate  on  the  Treatment  of  Consumption,  and 
how  far  can  Cases  be  grouped  for  Treatment  in  Certain  Climates?"  by 
C.  Theodore  Williams,  M.D.,  Transactions  of  the  British  Congress  on 
Tuberculosis.    London,  1901,  vol.  iii.,  p.  14. 

^  Die  Tuberhulosesterblichkeit  der  Schweiz  und  die  zur  Bekdmffung 
der  Tuberkulose  daselbst  im  letzten  Jahrzehnt  gemachten  Anstrengungen, 
von  Dr.  Schmid,  Direktor  des  Schweizerischen  Gesundheitsamts  in  Bern. 
Tuberculosis.     Berlin-Charlottenburg,   1912,  vol.  xi.,  p.  352. 

"'^  La  cure  de  Soleil,  par  Dr.  A.  Rollier.     Paris  et  Lausanne,  1914. 

^  For  further  details  concerning  the  stations  in  the  Rocky  Mountains, 
reference  should  be  made  amongst  others  to  the  following  : 

(i)  Rocky  Mountain  Health  Resorts,  by  Charles  Denison,  M.D.,  Boston, 
i88i ;  also  Dr.  Denison's  Climatic  Mafs  of  the  United  States,  1885. 

(2)  Aero-therafeutics,  or  the  Treatment  of  Lung  Diseases  by  Climate, 
by  Charles  Theodore  Williams,  M.D.     London,  1904. 

(3)  '«)  A  Handbook  of  Medical  Climatology,  by  S.  Edwin  Solly,  M.D., 
M.R.C.S.  London,  1897.  {b)  "  The  Health  Resorts  of  the  United 
States,"  by  Edwin  Solly,  M.D.,  in  Dr.  Hale  White's  Textbook 
of  Pharinacology  and  Therapeutics,  p.  965.     London,   1901. 

(4)  A  Handbook  of  Climatic  Treatment,  by  William  R.  Huggard, 
M.D.,  p.  257  et  seq.     London,  1906. 

'  The  Place  of  Climatology  in  Medicine,  by  William  Gordon,  M.A., 
M.D.,  F.R.C.P.,  p.  31.     London,  1913. 

^  The  South  and  East  African  Y ear  Book  and  Guide,  edited  annually 
by  A.  Samler  Brown,  F.R.M.S.,  and  G.  Gordon  Brown,  F.R.G.S.  London, 
Edition  1920. 

"  For  further  details  in  regard  to  the  climatology  of  Bloemfontein  we 
must  refer  to  [a)  the  table  in  the  Appendix  of  the  last  edition  of  this 
work,  p.  662 ;  and  [b)  The  Climate  of  the  Continent  of  Africa,  by  Alexander 
Knox,  B.A.  (Cantab.),  F.R.G.S.     Cambridge,  1911,  p.  433. 

"  Travel  and  Adventure  in  South-East  Africa,  by  Frederick  Courteney 
Selous,  C.M.Z.S.,  p.  80.     London,  1893. 

"  Sixth  Annual  Report  of  the  King  Edward  VII.  Sanatorium,  Midhursi, 
1912,  p.  46. 


CHAPTER  XLVI 

ON  CLIMATIC  CHANGE  IN  THE  TREATMENT  OF  PULMONARY 

TUBERCULOSIS— (Coniinued) 

Marine,  Maritime,  and  Inland  Climates. 

Perhaps  such  practical  suggestions  as  we  have  to  offer  with 
regard  to  the  selection  of  marine  and  maritime  climates,  and 
the  inland  climates  of  the  plains,  will  be  most  convenient  for 
reference  if  arranged  under  seasonal  headings. 

Autumn  (Septem^ber,  October,  and  Noventber). — At  this 
period  of  the  year  the  marine  and  maritime  climates  are 
especially  suitable,  since  during  the  latter  part  of  the  season, 
when  the  leaves  are  falling  and  rotting  on  the  ground,  the 
inland  country  districts,  wherever  there  are  many  trees,  are 
eminently  unfitted  for  cases  of  chest  disease  or  delicacy.  Ex- 
tensive pine  districts,  if  on  high  ground,  form  an  exception  to 
this  general  rule.  During  the  first  two-thirds  of  the  autumn 
season  the  moorland  districts  of  Scotland,  Yorkshire,  and 
Devonshire,  and  such  dry  localities  as  Malvern  and  Tunbridge 
Wells,  are  also  well  adapted  for  pulmonary  cases. 

Seaside  resorts  are  characterised  by  abundant  air  space, 
great  purity  of  air,  with  relative  excess  of  ozone  and  of 
moisture,  and  an  equable  temperature,  with  great  freedom 
from  dust.  As  the  season  advances  the  temperature  is  also 
relatively  warmer,  as  well  as  more  equable,  than  in  inland 
districts.^ 

The  most  material  advantages  of  popular  seaside  resorts, 
however,  are  the  abundant  accommodation  and  variety  of 
food  which  they  afford  to  invalids,  with  a  constant  and  inex- 
haustible reservoir  of  the  purest  air,  and  great  facilities  in  the 
form  of  diy,  level  walks,  sheltered  seats,  carriages,  bath-chairs, 
and  so  forth.  For  the  first  half  of  the  autumn  season.  Northern 
and  East  Coast  places  on  our  own  shores  may  be  selected — 
Nairn,   Scarborough,   Skegness,   Clacton,    Margate,    Clifton' 

^55 


654  DISEASES   OF  THE  LUNGS   AND   VLEXIRM 

ville,  Broadstairs,  Ramsgate,  Folkestone  or  Eastbourne. 
During  the  latter  part,  Hastings,  Eastbourne,  Brighton,  Vent- 
nor,  Bournemouth,  Torquay,  Newquay,  Teyiby,  Grange,  etc. 
The  more  bracing  places  should  be  chosen  for  those  of 
strumous  type,  and  with  no  marked  tendency  to  laryngeal  or 
bowel  complications;  and  a  residence  at  these  more  bracing 
resorts  with  an  easterly  aspect  may  often  be  extended  far  on 
towards  Christmas,  or  even  into  January.  In  hsemorrhagic 
cases,  and  those  with  larynx  and  bowel  comphcations,  the 
softer  climates  of  Hastings,  Ventnor,  Torquay,  Weymouth, 
Falmouth  and  Tenby  are  as  a  rule  preferable.  In  cases  of 
nervous,  irritable  temperaments,  with  disposition  to  neuralgia, 
sleeplessness,  and  torpidity  of  the  liver,  modified  sea  climates, 
such  as  can  be  obtained  a  little  inland,  at  Bournemouth,  Paign- 
ton and  St.  Mary  Church,  often  agree  better. 

Of  places  on  the  Continent,  Innsbruck,  Meran  (Austrian 
Tyrol),  or  Montreux,  Chexbres,  and  a  few  other  Swiss  resorts, 
may  be  advised.  These  latter  places  are  also  convenient  for 
those  who  contemplate  the  Riviera  or  Swiss  mountains  for 
the  winter,  and  at  either  Meran  or  Montreux  the  stay  may  be 
prolonged  into  the  winter  months. 

Sea  Yoyages.^These  have  enjoyed  in  the  past  a  great  repu- 
tation in  the  treatment  of  phthisis.  The  late  Dr.  Theodore 
Williams-,  in  his  Lumleian  Lectures  comparing  the  results 
given  by  different  climates,  found  that  sea  voyages  yielded  in 
his  statistics  a  larger  percentage  of  recoveries  than  the 
Riviera  or  the  home  climates,  and  were  second  only  to  the 
higher  altitudes. 

We  must  say  at  once,  however,  that,  though  good  results 
have  been  undoubtedly  obtained  in  the  past  in  suitable  cases 
from  sea  voyages,  yet  it  is  a  form  of  treatment  which  is 
clearly  far  from  ideal.  The  patient  may,  under  favourable 
conditions,  enjoy  abundance  of  fresh  air  during  the  day,  but 
at  night,  even  in  fine  weather,  his  cabin  can  rarely  fail  to  bv'^ 
stuffy,  while  in  stormy  seas  and  with  port-holes  closed  the  air 
may  become  very  foul.  A  voyage,  therefore,  is  by  no  means 
a  perfect  open-air  life,  as  is  sometimes  hastily  imagined.  To 
this  drawback  we  must  add  the  possibility  of  sea-sickness,  the 
changes  of  temperature  to  Avhich,  as  the  voyage  proceeds,  the 
patient  is  exposed,  together  with  the  enervating  influence  of 
the  moisture  and  heat  during  the  passage  through  the  tropics. 


ON  CLIMATIC  CHANGE  655 

Further,  should  the  patient  become  ill,  or  have  a  recrudescence 
of  his  malady,  it  will  not  be  easy  to  obtain  for  him  the 
requisite  nursing  or  proper  food.  It  is  clear,  therefore,  that 
the  scope  of  the  ordinary  sea  voyage  is  a  restricted  one. 
Whether  it  will  ever  be  possible,  as  has  been  suggested,  to 
have  a  vessel  arranged  as  a  floating  sanatorium  on  a  suffi- 
ciently ample  and  luxurious  scale  for  the  treatment  of  patients 
at  some  ideal  locality  on  the  high  seas  is  a  matter,  perhaps, 
worthy  of  consideration.^  The  idea  would  not  be  difficult 
of  realisation  to  a  man  of  ample  means,  with  a  well-equipped 
private  yacht. 

The  sea  climate  contrasts  with  that  of  the  mountain  valley 
in  excessive  moisture,  comparative  equability  of  temperature, 
and  high  and  variable  atmospheric  pressure;  in  freedom  from 
organic  and  inorganic  dust  they  resemble  each  other.  And  it 
is  instructive  to  note  that,  allowance  being  made  for  individual 
peculiarities,  the  same  class  of  cases  do  well  under  both  con- 
ditions. 

Patients  with  active  tuberculous  disease  should  be  strictly 
forbidden  to  take  a  sea  voyage,  the  only  exceptions  being  in 
the  case  of  those  who  have  friends  and  better  home  surround- 
ings at  their  proposed  destination.  Cases  of  chest  delicacy, 
on  the  other  hand,  especially  in  those  with  overworked  ner- 
vous systems,  quiescent  disease  with  defective  sanguification, 
and  early  cases  associated  with  enlarged  glands — the  so- 
called  "  scrofulous  phthisis  "  of  earlier  writers — do  well  on  a 
voyag'e.  But  even  for  these  the  voyage  should  not  be 
countenanced  unless  the  patient  have  been  already  carefully 
observed  for  some  time  at  home,  to  be  certain  that  the  disease 
shows  no  activity,  or,  better  still,  have  already  spent  some 
time  in  a  sanatorium  where  he  has  been  carefully  watched, 
and  instructed  in  regard  to  his  personal  hygiene  and  mode  of 
life.  Haemorrhagic  cases  and  those  complicated  with  dys- 
pepsia or  diarrhoea  are  not  adapted  for  sea  voyages. 

A  fundamental  question  to  ask  a  patient  for  whom  one  is 
contemplating  the  recommendation  of  a  voyage  is,  whether 
he  is  a  g-ood  sailor  and  eats  and  sleeps  well  on  board  ship. 
Unless  a  fairly  confident  affirmative  answer  can  be  given  to 
these  questions,  it  will  be  best  not  to  advise — in  the  first 
instance,  at  least — any  sea  trip  longer  than  to  the  Canaries, 
or  perhaps  the  Cape.     Unless,  also,  the  voyage  can  be  taken 


656  DISEASES   OF  THE  LUNGS   AND   PLEURA 

with  first-class  accommodation  and  with  every  possible  luxury, 
including  a  deck-cabin,  so  as  to  insure  as  much  ventilation 
as  possible,  it  should  not  be  advised.  Moreover,  it  is  impor- 
tant that  some  definite  plan  be  agreed  upon  beforehand  as  to 
route  and  destination.  A  certain  steadiness  of  purpose  in  this 
respect  is  essential  to  those  who  would  profit  by  their  tem- 
porary expatriation.  Patients  who  go  to  distant  regions  in 
search  of  health,  and  find  it  on  the  way,  frequently  by  the  time 
of  their  arrival  have  forgotten  their  original  purpose,  and 
scamper  about  over  various  climatic  areas  in  a  manner  calcu- 
lated entirely  to  thwart  the  object  with  which  their  journey 
was  designed. 

We  may  here  again  refer  to  the  restrictions  placed  by  the 
Governments  of  Australia  and  New  Zealand,  of  Canada,  the 
United  States,  and  the  Union  of  South  Africa  upon  entry  into 
their  territories  of  pa,tients  suffering-  from  tuberculosis,  and 
the  advisability  of  communicating  with  the  representatives 
in  London  of  the  various  Governments  concerned  before  the 
patient  leaves  England,  so  that  he  may  not  find  that  he  is 
precluded,  as  an  unsuitable  case,  from  landing  when  he 
reaches  his  destination  (see  p.  636). 

The  latter  part  of  the  autumn,  as  soon  as  the  equinoctial 
gales  are  over,  is  the  best  time  for  commencing  a  long  sea 
voyage.  Shorter  trips  are  advantageously  taken  in  the  earlier 
part  of  the  season. 

In  former  editions  of  this  work  the  long  sea  voyage  to  Aus- 
tralasia by  sailings-vessels  round  the  Cape  was  considered.  But 
at  the  present  day  well-found  vessels  of  the  kind  are  not 
available,  and  only  by  special  arrangement  with  a  few  trading- 
vessels  still  remaining  can  this  restful  and  health-giving 
voyage  be  entertained  by  those  thorough  sons  of  the  sea  who 
can  enjoy  it.  It  will  be  taken  for  granted,  therefore,  that  the 
Orient,  P.  and  O.,  R.M.S.P.,  or  some  other  great  line  of 
steamers,  will  be  made  use  of  for  the  voyage. 

Having  reached  Australia  patients  should  only  remain  at 
Melbourne  the  briefest  possible  time,  the  climate  there  being 
most  unsuitable  for  chest  diseases;  nor  is  that  of  Sydney  very 
suitable  at  the  time  of  year  calculated  for  arrival. 

Hobart,  in  Tasmania,  is  easy  of  access  from  Melbourne, 
either  by  steamer  direct,  or  to  Launceston  and  thence  by  rail. 
The  climate  of  Hobart  is  perfect  from  November  to  May,  and 


ON   CLIMATIC   CHANGE  657 

the  hotels,  boarding-houses,  and  apartments  of  the  neighbour- 
hood are  good.  Children  do  well  there,  and  a  patient  with 
arrested  disease  who  desired  to  remain  at  the  antipodes  dur- 
ing our  worst  months,  with  the  view  of  returning  home  about 
June,  could  not  do  better  than  spend  the  interim  at  Hobart. 
In  the  case  of  robust  and  independent  patients  with  little  or 
no  actual  disease,  but  who,  invigorated  by  their  journey  out, 
desire  simply  to  lead  a  more  outdoor  Hfe  than  is  possible  in 
their  own  country,  certain  parts  of  Australia  are  suitable. 
For  such  the  neighbourhood  of  Bendigo,  north  of  the  Vic- 
torian range  of  mountains,  the  Riverina,  in  New  South 
Wales,  or  Wai'mick  and  the  Darling  Downs,  in  Queensland, 
afford  ample  fields  for  pastoral  life.  Of  late  the  Blue  Moun- 
tains, not  far  from  Sydney,  have  acquired  a  reputation  as  a 
health  resort  for  sufferers  from  consumption,  and  yearly 
attract  many  Australian  patients. 

It  is  often  of  the  highest  importance  for  consolidating  a 
cure  to  spend  at  least  two  winters  away,  and  the  patient  can 
for  this  purpose  remain  at  Hobart  until  May,  and  then  visit 
Sydney  or  the  interior  of  Victoria,  Queensland,  or  New  South 
Wales;  or  an  outdoor  sheep-farming  life  may  be  led  in 
Northern  or  Western  Victoria,  except  for  the  two  hottest 
months  of  December  and  January,  which  should  be  spent  in 
Tasmania  or  New  Zealand. 

The  climate  of  New  Zealand  may  be  said,  generally  speak- 
ing, to  be  an  improvement,  for  chest  invalids,  upon  Southern 
England,  having  more  sunshine  and  warmth,  and  greater  pos- 
sibilities of  outdoor  life,  but  with  a  decidedly  stormy  and 
variable  climate,  even  in  summer  the  nights  being  often  very 
cold.  The  choicest  parts  of  New  Zealand  are,  perhaps,  Napier 
in  Hawkes  Bay,  North  Island,  and  Nelson  in  Tasman  Bay, 
South  Island.  These  stations  are  warm,  fairly  equable,  and 
afford  good  accommodation.  The  interior  of  Otago  is  spoken 
well  of,  but  it  is  colder  than  the  other  places  named. 

A  plan  of  combining  a  shorter  voyage  with  residence  away 
from  England  for  twelve  months  would  be  by  P.  and  O. 
steamer,  so  timed  as  to  reach  Calcutta  after  Christmas,  spend- 
ing January  and  February  there,  and  then  proceeding  to  Dar- 
jeeling,  where  the  rest  of  the  year,  from  March  to  November, 
might  be  passed,  returning,  after  making  a  further  stay  at 
Calcutta,  by  the  Riviera  gradually  homewards. 

42 


658  DISEASES   OF  THE  LUNGS   AND   PLEURA 

By  one  or  other  of  the  plans  just  suggested,  the  advantage 
gained  by  a  long  sea  voyage  may  be  still  further  improved, 
one  or  two  winters  being  escaped,  and  the  patient  returning 
home  at  the  beginning  of  the  second  or  third  summer.  In 
favourable  cases,  after  a  year  or  two  devoted  to  recovery, 
some  suitable  locality  may  be  fixed  upon  for  permanent  resi- 
dence. 

Winter  (December,  January  and  February). — For  those 
patients  with  pulmonary  tubercle  in  an  early  and  quiescent 
stage  who  cannot  go  abroad  in  the  winter,  there  are  still 
English  places  fairly  well  adapted  to  meet  their  requirements 
— viz.,  the  maximum  enjoyment  of  air  and  exercise  out  of 
doors.  In  cases  in  which  only  a  period  of  three  months  can 
be  spent  abroad,  it  is  far  preferable  to  select  the  three  spring 
than  the  three  winter  months;  for  with  the  setting  in  of  the 
winter  frosts  there  is  no  long"er  the  same  harmful  influence 
to  be  dreaded  in  inland  leafy  districts  as  in  the  late  autumn. 
Those  patients  who  have  homes  in  our  inland  counties  situated 
on  dry,  porous  soils,  with  sunny  exposure  and  fairly  protected 
from  cold  winds,  may  do  well  there,  and  many  invalids,  with 
a  short  change  in  the  autumn  and  spring,  will  do  best  thus 
to  spend  the  winter  months  at  their  own  homes.  After 
years  of  weary  travel,  patients  not  infrequently  find  their 
immunity,  and  can  then  remain  in  their  own  home  district, 
provided  conditions  are  fairly  favourable. 

Hastings  and  St.  Leonards,  Ventnor,  Bournemouth,  Teign- 
m>o.uth,  Torquay,  Falmouth,  Penzance  and  Tenby  (south  side), 
may  be  selected  by  those  not  well  situated  at  home;  of  these 
places  the  air  of  Teignmouth,  Torquay,  Falmouth,  and  Tenby, 
is  softer  than  at  the  others,  and  more  suitable  for  cases  with 
dry,  harsh  skins  and  irritable  mucous  membranes.  It  is  to  be 
remembered  that,  whereas  at  Hastings,  St.  Leonards,  and 
Ventnor  the  coast  residences  should  be  chosen,  and  the 
uplands  only  in  special  instances,  at  Torquay,  on  the  other 
hand,  the  quay  residences  are  cold,  damp  and  misty  from 
defective  sun  exposure  and  imperfect  circulation  of  air,  whilst 
the  terraces  on  the  slopes  are  comparatively  warm,  sunny  and 
dry.  St.  Mary  Church,  a  suburb  of  Torquay,  suits  some 
people  better,  being  more  withdrawn  from  the  sea. 

Bournemouth  is  a  sea  climate,  much  modified  by  the  exten- 
sive moorlands  behind  it  and  the  pine  growths,  amidst  which 


ON   CLIMATIC   CHANGE  659 

many  of  the  best  houses  are  placed,  although  of  late  years  the 
spread  of  the  town  has,  unfortunately,  led  to  the  cutting  down 
of  many  of  these  trees.  The  habitations  are  more  isolated 
and  stand  farther  back  from  the  sea  than  at  other  places,  and 
these  facts  render  the  climate  a  happy  mixture  of  marine  and 
moorland,  suitable  for  many  people  with  whom  a  more  purely 
sea  air  disagrees.  An  asthmatic  or  bronchial  element  would 
sugg"est  Bournemouth  in  preference  to  other  places.  In  point 
of  warmth  Bournemouth  is  not  to  be  preferred  to  any  of  the 
other  South-Coast  resorts;  like  most  other  large  places,  how- 
ever, such  as  Torquay  and  Hastings,  it  possesses  many  shel- 
tered nooks  well  known  to  resident  practitioners — indeed, 
these  places  may  be  said  to  be  "  full  of  climates ! " 

The  Riviera,  that  narrow  strip  of  land  bordering  the 
Mediterranean,  and  bounded  and  protected  on  the  north  by 
the  Maritime  Alps,  extends  from  Hyeres  eastwards.  The 
portion  between  Hyeres  and  Genoa  is  known  as  the  Western 
Riviera,  or  Riviera  di  Ponente,  and  constitutes  the  Riviera 
proper;  most  of  the  well-known  health  resorts  are  situated  in 
it.  From  Genoa  to  Spezzia,  or  even  to  Leghorn,  runs  the 
Eastern  or  Levantine  Riviera.  This  at  the  present  time  is 
less  well  known,  and  in  pre-war  times  was  less  expensive; 
but  its  climate,  though  moister  and  possibly  somewhat  colder, 
does  not  otherwise  differ  materially  from  that  of  its  western 
rival. 

The  Riviera  climates  have  in  common  the  advantages  of 
warmth,  brilliancy,  and  comparative  dryness.  They  are  easily 
accessible,  and  the  larger  resorts  possess  excellent  accommo- 
dation. They  differ  among  themselves  in  exposure  to  wind, 
especially  the  cold  north-west  wind  or  mistral,  and  also  in  the 
degree  of  prevalence  of  dust.  Certain  of  these  points  are 
brought  out  by  the  meteorological  data  which  we  have  col- 
lected (see  table,  p.  643).  From  these  it  will  be  seen  that  the 
mean  temperature  for  the  six  winter  months  (November  to 
April)  at  Nice,  Cannes,  Mentone,  and  San  Remo  varies 
between  50-0°  and  52-0°,  that  of  London  (Regent's  Park) 
being  41-9°,  whilst  Hastings,  Bournemouth,  and  Torquay 
yield  means  of  42-5°,  43-8°,  and  45-1°  respectively.  Records 
are  wanting  to  enable  us  to  compare  accurately  the  amount 
of  sunshine  on  the  Riviera  with  that  of  other  stations,  but 
that  it  is  greatly  in  excess  of  that  enjoyed  at  English  resorts, 


660  DISEASES   OF   THE  LUNGS    AND   PLEURA 

and,  owing  to  the  dryness  of  atmosphere,  of  a  brilliancy  rarely 
seen  with  us,  may  be  accepted. 

The  rainfall  during  the  winter  months  may  be  taken  at 
about  17  inches  (Nice,  15-5  inches;  Cannes,  19' i  inches),  which 
is  somewhat  in  excess  of  that  at  Regent's  Park  (11 '31  inches) 
and  of  Hastings  (i4'5o  inches),  but  not  very  different  from 
that  of  Bournemouth  (i5'93  inches)  and  of  Torquay  (i7'37 
inches).  Nevertheless,  owing  to  the  rain  coming  rather  in 
storms,  and  the  sky  then  clearing,  the  number  of  rainy  days 
on  the  Riviera  is  materially  less  than  in  our  own  climate. 
Thus,  at  Nice,  Cannes,  and  Mentone,  there  were  respectivelv 
43,  43,  and  47  rainy  days  during  the  six  winter  months,  while 
in  London  (at  Regent's  Park),  Torquay,  and  Hastings  they 
amounted  to  83,  90,  and  loi  during  the  same  period.  The 
dryness  of  the  atmosphere  is  further  indicated  by  the  records 
of  mean  relative  humidity  at  9  a.m..  Dr.  Marcet's  figures  for 
six  winters  at  Cannes  yielding  a  percentage  of  73,  as  com- 
pared with  82  and  84  for  Torquay  and  Regent's  Park  respec- 
tively. 

Such  are  the  more  important  characters  of  the  cHmate  of 
this  favoured  region,  and  experience  shows  that  one  or  other 
of  the  resorts  along  its  shores  is  generally  suited  for  those 
cases  for  whom  the  elevated  stations  are  not  desirable. 
Phthisical  patients  with  poor  general  vitality  will  do  best  tc 
spend  the  first  winter,  at  all  events,  in  the  Riviera.  In  some 
cases,  also,  in  which  the  necessity  for  change  of  climate  occurs 
when  cold  weather  has  already  set  in,  it  is  more  prudent  to 
select  one  of  the  warmer  resorts,  with  the  view,  perhaps,  of 
higher  ground  in  the  ensuing  autumn. 

There  are,  moreover,  some  early-stage  cases  of  phthisis, 
complicated  with  threatened  or  actual  laryngeal  or  bowel 
trouble,  in  which  the  prognosis  is  grave,  and  in  which  the 
cold  air  of  the  mountains  is  not  to  be  advised.  In  such  cases, 
provided  the  patient  can  go  abroad  with  every  comfort  and 
accompanied  by  his  family  or  nearest  friends,  rehef  of  symp- 
toms and  lessened  activity  of  progress  may  be  effected  by  a 
visit  to  one  of  the  sheltered  Riviera  resorts. 

Children  and  young  adults,  especially  girls,  with  a  delicate 
family  history,  who  have  had  acute  bronchial  or  pulmonary 
affections,  may,  by  one  or  two  winters  spent  in  the  Riviera, 
completely    and    permanently    recover.     To    elderly    people, 


ON  CLIMATIC  CHANGE  66 1 

again,  with  phthisis,  in  whose  tissues  senile  decay  has  already 
commenced,  these  warmer  climates  are  admirably  adapted. 

A  most  important  point  to  be  borne  in  mind  by  those  who 
send  invalids  to  the  Riviera  is  that  warm  woollen  undercloth- 
ing should  be  enjoined,  and  that  they  should  be  especially 
warned  to  be  within  doors  half  an  hour  before  sundown,  a 
fall  of  several  degrees  of  temperature  taking  place  abruptly 
at  this  time.  The  patient  should  accordingly  never  run  the 
risk  of  being  belated  out  of  doors  without  special  wraps, 
although,  properly  clothed,  he  may  often  with  advantage  go 
out  ag'ain  later  in  the  evening. 

Of  the  Riviera  resorts,  the  following,  as  we  pass  from 
Hyeres  eastwards,  are  the  more  important : 

Hycres. — The  west  end  of  Hyeres  is  the  best  part,  its  eleva- 
tion permitting  of  superior  drainage.  Somewhat  removed 
from  the  sea,  Hyeres  enjoys  a  slightly  modified  sea  climate, 
and  is  partially  protected  from  winds  by  the  chain  of  islands 
parallel  to,  and  two  or  three  miles  distant  from  the  shore. 
The  climate  is  accordingly  more  soothing  than  many  of  the 
Riviera  stations,  and  excitable  people  of  the  "erethic"  type 
will  probably  do  better  here  than  elsewhere.  Some  forms  of 
asthma,  bronchitis,  and  emphysema,  are  also  benefited.  From 
November  to  February  the  climate  is  at  its  best,  and  during 
this  period  may  be  recommended  for  cases  of  advanced  but 
quiescent  tubercle,  and  those  complicated  by  albuminuria. 
In  February  and  March  the  mistral  is  sometimes  severely  felt. 

Costebelle,  two  miles  south  of  Hyeres,  on  the  Hermitage 
Hill,  200  feet  above  the  town,  is  quieter  and  less  dusty.  It 
possesses  excellent  hotel  accommodation,  and  may  be  recom- 
mended for  the  same  class  of  cases  for  which  Hyeres  is  suited. 
There  are  excellent  golf-links  in  the  district. 

Cannes. — For  prolonged  residence  Cannes  affords  the  most 
varied  attractions,  perhaps,  of  any  of  the  Riviera  stations. 
Yet  in  the  pleasures  of  its  social  life  lurks  a  danger  to  the 
invalid  ag"ainst  which  he  must  be  on  his  guard;  for  he  must 
ever  remember  that  his  object  is  to  regain  his  health,  and  that 
this  can  only  be  effected  by  rigidly  ordering  his  Hfe  aright 
under  proper  medical  supervision,  by  keeping  early  hours,  and 
by  eschewing  for  the  most  part  the  numerous  gaieties  for 
which  the  season  at  Cannes  is  famous.  The  upland  parts  of 
the  town,  away  from  the  shore,  are  best  suited  for  residence. 


662  DISEASES   OF  THE  LUNGS   AND  PLEURA 

The  climate  (see  table,  p.  643)  is  decidedly  bracing  and  bril- 
liant, though  somewhat  changeable.  Cases  of  quiescent 
phthisis,  of  strumous  type,  with  lax  secreting  membranes  and 
non-pyrexial  sweatings;  cases  of  anaemia,  senile  forms  of 
bronchitis,  emphysema,  asthma;  and  persons,  both  young  and 
old,  recovering  from  acute  chest  disease,  do  well  here.  For 
patients,  on  the  other  hand,  of  highly  nervous  temperament, 
with  a  disposition  to  sleeplessness,  Cannes  is  not  so 
well  suited.  In  this  large  district  there  are  many  climates, 
and  it  is  safest  to  take  local  advice  as  to  any  precise  locality 
for  prolonged  residence. 

Cimiez,  a  suburb  of  Nice,  is  well  suited  for  cases  of  asthma, 
for  neuralgic  patients,  and  bad  sleepers.  It  is  less  liable  to 
variable  winds  than  the  town  of  Nice.  For  elderly  people 
Nice  has  the  advantage  of  level  walks  and  promienades  and 
town  life,  with  the  brilliant  Riviera  sunshine;  and  there  are 
many  sheltered  parts  in  the  Carabagel  quarter,  in  which  more 
delicate  patients  will  find  protection  from  cold  winds. 

Beaulieu,  situated  between  Nice  and  Monte  Carlo,  is  won- 
derfully warm  and  sheltered,  and  is  admirably  suited  for 
patients  needing  such  a  winter  climate. 

Monte  Carlo  and  Les  Moulins,  in  the  Eastern  Bay  of  the 
principality  of  Monaco,  are  amongst  the  choicest  spots  of 
the  Riviera  for  residence,  the  dwellings  being  between  200 
and  300  feet  above  the  sea-level,  well  protected  from  mistral 
by  mountains  behind,  yet  with  abundant  air  circulation.  These 
places  are  to  be  recommended,  however,  only  for  wealthy 
people  in  limited  numbers.  Cap  d'Ail  La  Turbie,  in  the 
neighbourhood,  where  there  is  a  good  hotel,  is  well  adapted 
for  pulmonary  convalescents  without  any  declared  disease. 

Mentone. — This  resort,  especially  the  East  Bay,  is  warmer 
and  more  sheltered  than  the  other  stations,  with  the  exception 
of  Beaulieu,  and  yet  has  a  good  circulation  of  air.  Many  real 
invalids  accordingly  make  their  winter-quarters  here.  The 
mean  temperature  for  the  six  winter  months  may  be  taken  as 
52°  (Bennett).  A  glance  at  the  table  on  p.  643  will  show  that 
this  is  slightly  higher  than  the  corresponding  figures  for  San 
Remo,  Cannes,  and  Nice.  Mentone  is  well  adapted  for  resi- 
dence in  cases  of  chronic  bronchial  catarrh,  gouty  bronchitis, 
and  phthisis  with  albuminuria.  Asthmatics  frequently  also  do 
well  in  Mentone.     Cases  of  somewhat  advanced  phthisis  find 


ON  CLIMATIC   CHANGE  66^ 

this  locality  soothing;  and  persons  who  lead,  from  cardiac 
diseases  or  other  causes,  lives  of  enforced  inactivity  will  often 
profit  by  sojourn  here.  Patients  in  whom  haemorrhage  is  a 
marked  feature  are  not  well  suited  for  this  very  marine 
climate,  a  more  inland  locality  being  better  adapted  to  them. 
The  West  Bay  of  Mentone  is  somewhat  fresher  and  more 
bracing  than  the  East,  but  the  sanitation  of  both  districts  is 
equally  good.  Cap  Martin,  a  bracing  peninsular  suburb  of 
Mentone,  with  an  excellent  hotel,  is  well  adapted  for  wealthy 
convalescent  patients. 

San  Reino  is  a  charming  station,  which  has  grown  steadily 
in  popularity.  It  occupies  a  sheltered  position  some  eight 
miles  east  of  Bordighera,  itself  a  growing-  health  resort.  Its 
winter  climate  (see  table,  p.  643)  resembles  that  of  Mentone, 
although,  as  we  have  seen,  it  is  a  trifle  colder  and  not  so  well 
protected  from  wind.  It  is  admirably  adapted  for  fairly 
quiescent  cases  of  consumption,  especially  those  associated 
with  a  languid  and  feeble  circulation.  Cases  of  heart  disease 
and  emphysema  do  well  at  this  resort,  where  a  long  stretch 
of  level  walk  extends  along  the  front  and  through  the  newer 
part  of  the  town. 

In  aadition  to  the  stations  which  we  have  named,  there  are 
many  other  places  worthy  of  note  along  the  northern  coast 
of  the  Mediterranean.  Such  are  Alassio  and  Pegli,  on  the 
Western  Riviera;  Nervi,  Porto fino,  Rapallo,  and  others  on  the 
Eastern  or  Levantine  Riviera,  the  latter  not  as  yet  fashion- 
able, and  consequently,  before  the  war,  more  moderate  in 
price.  Algeciras  and  Malaga,  on  the  south  coast  of  Spain,  and 
Monte  Estoril  in  Portugal,  not  far  from  Lisbon,  may  also  be 
mentioned.  All  have  their  merits,  and  at  Nervi  and  Porto- 
fino  and  Algeciras  good  hotel  accommodation  may  be  ob- 
tained. 

On  the  way  to  the  Riviera,  Arcachon,  Biarritz,  and  Pau  may 
be  mentioned.  Arcachon,  in  the  district  of  the  Landes,  some 
thirty  miles  south-west  of  Bordeaux,  although  colder  than 
the  more  southern  stations,  is  well  adapted  for  many  cases  of 
arrested  pulmonary  tuberculosis  with  excitable  rather  than 
depressed  nervous  system.  The  winter  villas  amongst  the 
pines  are  the  most  suitable,  and  riding  exercise  can  be  enjoyed 
amongst  the  interminable  pine  forests,  which  afford  consider- 


664  DISEASES   OF  THE  LUNGS   AND   PLEURA 

able  shelter  from  the  spring  winds.  Some  cases  of  chronic 
phthisis  with  excessive  secretion  do  well  here.  The  climate 
is  also  well  adapted  for  asthma. 

Biarritz^  on  the  shores  of  the  Bay  of  Biscay,  some  sixteen 
miles  from  the  Spanish  border,  possesses  a  highly  marine 
climate.  It  is  suitable  in  the  late  autumn  and  early  winter 
and  later  spring  months  for  threatened  cases  of  consumption, 
especially  in  children  for  whom  the  bracing  effect  of  the 
Atlantic  breezes  may  be  desired.  It  is  too  much  exposed  to 
wind  for  most  cases  of  declared  disease.  People  with  a  dis- 
position to  neuralgia  do  not  do  well  here. 

Pau,  an  inland  station  in  the  Basses-Pyrenees,  about  sixty 
miles  south-east  of  Biarritz,  possesses  a  winter  climate  some 
five  degrees  colder  than  that  of  the  Riviera;  its  rainfall  and 
humidity  are  also  gTeater.  The  atmosphere  is,  however,  very 
still,  and  winds  are  but  Httle  prevalent.  Cases  of  chronic 
bronchial  and  laryngeal  catarrh,  and  some  elderly  patients  who 
do  not  flourish  at  the  Riviera  climates,  are  better  here.  It  is  a 
sedative  climate,  with  magnificent  surroundings  and  sheltered 
walks  and  drives,  and  many  social  attractions. 

Algiers,  on  the  southern  shores  of  the  Mediterranean,  has  a 
mean  winter  temperature  of  587°  (see  table,  p.  643),  between 
8°  and  9°  higher  than  that  of  Cannes  or  Nice,  but  its  climate  is 
moister  than  that  of  the  Riviera  resorts.  The  rainfall, 
23  inches  from  November  to  April  inclusive,  is  also  greater, 
whilst  the  days  on  which  rain  falls  are  nearly  double, 
eighty-four  (almost  identical  with  that  of  London),  as  opposed 
to  forty-three  at  Nice  and  at  Cannes.  Algiers  is,  however,  but 
little  affected  by  mistral,  and  rarely  visited  during  the  winter 
and  spring  months  by  the  dusty  south  wind  or  sirocco. 

The  climate  is  suitable  for  cases  of  chronic  bronchitis,  em- 
physema, quiescent  phthisis,  even  if  somewhat  advanced,  and 
for  some  cases  of  asthma.  For  all  these  affections  the  Mus- 
tapha  Superieur  quarter  of  Algiers  is  to  be  selected. 

Egypt. — The  warm,  very  dry  winter  climate  of  Eygpt,  with 
its  pure  desert  air,  brilliant  sunshine,  low  degree  of  humidity, 
and  but  scanty  rainfall — factors  well  brought  out  by  the 
meteorological  data  relative  to  Helwan,  which  we  have  incor- 
porated in  the  table  on  p.  643 — would  seem  to  offer  consider- 


ON   CLIMATIC   CHANGE  665 

able  advantages  to  the  consumptive,  and  certain  cases  find 
relief  there.  Egypt  is  perhaps  best  suited  for  patients  v^ith 
quiescent  disease  but  continuing  secretion,  which  tends  to 
diminish  and  dry  up  under  the  favourable  climatic  conditions. 
It  is,  however,  less  easy  at  the  Egyptian  resorts  than  at  other 
places  which  we  have  considered  to  insure  that  continuous 
medical  supervision  which  is  so  essential  for  successful  treat- 
ment, or  for  the  patient  to  carry  out  the  regime  laid  down  for 
him,  even  if  so  minded.  Moreover,  experience  has  shown  that 
the  majority  of  cases  of  early  phthisis,  provided  they  have 
sufficient  vitality,  do  better  in  a  more  bracing  climate.  Still, 
we  have  known  cases  do  well  in  Egypt,  and  their  lesions  to 
remain  arrested  after  spending"  some  winters  there.  This 
climate  is  more  specially  adapted  for  the  chronic  bronchitic 
and  asthmatic  invalid. 

Those  who  go  to  Egypt  in  search  of  health  should  eschew 
Cairo,  with  its  gaieties  and  dust,  and  go  to  Mena  House  or 
Hclwdn,  not  far  from  Cairo,  or  to  Luxor  or  Assouan*  on  the 
banks  of  the  Nile  farther  south.  Dahabieh  excursions  up  the 
Nile  may  be  suggested  as  an  interesting  change  for  the 
wealthy,  although  under  no  circumstances  can  a  winter  in 
Egypt  be  passed  without  considerable  expense. 

The  Egyptian  season  ends  in  April,  when  the  weather  be- 
comes too  warm.  Patients  should  not  then  hurry  back  directly 
to  England,  very  possibly  to  find  there  the  winter  which  they 
have  successfully  eluded  so  far,  but  should  be  advised  to  stay 
at  some  intennediate  station,  perhaps  in  Sicily,  at  one  of  the 
Riviera  resorts,  or  on  the  Italian  lakes,  at,  for  example,  Varese 
or  Lugano,  until  the  end  of  May,  when  the  return  home  may 
be  sanctioned.  Meran  in  the  Austrian  Tyrol  or  Vernet-les- 
Bains  in  the  Pyrenees  may  also  be  recommended.  Another 
feasible  plan  is  to  take  the  P.  and  O.  boat  to  Gibraltar,  and 
cross  over  to  Algeciras,  where  excellent  accommodation  can 
be  found  at  the  hotel. 

Madeira  and  its  principal  town,  Funchal,  enjoy  a  warm, 
moist,  and  equable  climate,  abundant  sunshine,  and  freedom 
from  dust. 

The  temperature  records,  as  will  be  seen  from  the  table  on 
p.  643,  correspond  closely  with  those  of  Algiers.  Thus,  the 
mean  winter  temperature  at  Funchal  is  59"9°,  as  compared 


666  DISEASES   OF  THE  LUNGS   AND  PLEURA 

with  587°  at  Algiers;  while  the  range  is  slightly  less  (127°,  as 
against  13°).  The  winter  rainfall  is,  however,  smaller,  and 
the  number  of  rainy  days  materially  less  (fifty-three,  as 
opposed  to  eighty-four).  As  compared  with  the  Eng'lish  sta- 
tions, the  mean  winter  temperature  at  Funchal  is  some  15° 
higher  than  that  of  Torquay,  and  18°  higher  than  that  of 
London  (Regent's  Park).  The  winter  rainfall  is  considerably 
greater,  but  the  number  of  rainy  days  materially  less  (fifty- 
three  as  opposed  to  ninety  at  Torquay,  one  hundred  and  one 
at  Hastings). 

A  noticeable  feature  of  the  cHmate  is  its  equabiHty  and  the 
slight  difference  between  the  mean  temperatures  throughout 
the  year.  At  Funchal  the  mean  for  the  six  winter  months 
(November  to  April)  is  59'9°;  for  the  six  summer  months 
(May  to  October),  677°.  In  former  times  when  equability  and 
warmth  were  regarded  as  of  the  first  importance  in  the  treat- 
ment of  phthisis,  Madeira,  with  its  warm  marine  climate,  beau- 
tiful vegetation,  and  comparatively  easy  accessibility,  was 
much  resorted  to.  The  patients,  however,  from  the  Brompton 
Hospital  who  were  sent  to  winter  there  yielded  unsatisfactory 
results,  only  three  out  of  the  twenty  deriving  benefit,  and  the 
statistics  published  by  the  late  Dr.  Theodore  Williams*  in  his 
Lettsomian  Lectures  in  regard  to  his  Madeira  patients  were 
also  unfavourable.  At  the  present  time  opinion  is  in  favour 
of  a  colder  and  more  stimulating  climate,  provided  the  patient 
can  respond,  as  leading  more  readily  to  the  arrest  of  disease. 

In  cases  of  emphysema,  and  of  phthisis  with  a  good  deal 
of  attendant  bronchitis  and  emphysema,  and  especially  in  those 
of  older  years  in  whom  the  disease  has  supervened  upon  long- 
standing winter  cough,  the  climate  of  Madeira  will  be  found 
well  adapted  for  residence.  Patients  with  irritable  cough  and 
but  little  expectoration,  or  with  laryngeal  trouble,  provided  it 
be  not  too  advanced,  may  also  find  rehef  here,  such  cases 
being  as  a  rule  unsuitable  for  high  altitudes.  For  many  bron- 
chial and  some  asthmatic  affections,  particularly  those  asso- 
ciated with  renal  unsoundness,  Madeira  is  peculiarly  suited. 

At  different  elevations  from  Funchal,  up  to  a  height  of  2,000 
feet,  more  bracing  accommodation  can  be  obtained  than  in 
Funchal  itself,  so  that,  owing  to  the  coolness  of  the  summer 
the  patient  need  not  hurriedly  leave  the  island  the  moment 
the  winter  has  ended,  but  is  enabled  to  remain  in  comfort  until 


ON  CLIMATIC  CHANGE  66/ 

May  or  early  June,  when  he  can  more  safely  return  to  Eng- 
land. The  absence  of  dust  and  of  mosquitoes  is  especially 
to  be  emphasised  as  a  feature  of  this  climate. 

The  Canary  Islands  possess  a  climate  which  resembles  that 
of  Madeira,  but  is  somewhat  warmer,  less  moist,  and  more 
dusty.  It  may  be  recommended  for  similar  cases.  Oratava, 
in  the  island  of  Teneriffe,  or  Las  Palmas,  in  Grand  Canary, 
are  suitable  for  a  lengthened  stay;  and  the  latter  especially 
so  in  cases  in  which  a  rheumatic  element  is  present. 

We  have  observed  Santa  Cruz,  at  the  foot  of  Oratava,  to  be 
especially  suitable  for  asthmatic  cases. 

California. — The  climate  of  that  portion  of  the  State  of 
California  which  lies  south  of  Point  Conception  between  the 
mountains  and  the  Pacific,  is  characterised  by  mildness,  the 
winters  being  warm  and  spring-like,  with  abundant  sunshine, 
whilst  the  summers  are  cool.  The  rainfall  is  a  small  one,  but 
the  humidity,  owing  to  the  influence  of  the  ocean,  is  not  par- 
ticularly low,  and  fogs  in  the  morning  and  evening  are  by  no 
means  infrequent. 

The  climate  at  the  various  resorts  will  be  found  to  differ 
somewhat  according  to  local  conditions,  and  especially  with 
their  greater  or  less  proximity  to  the  coast;  but,  taking  the 
meteorological  data  of  the  city  of  Los  Angeles  as  an 
example,  we  may  note  that  in  point  of  temperature  the  records 
(see  p.  643)  show  a  climate  which,  so  far  as  this  feature  is  con- 
cerned, closely  approximates  to  that  of  Madeira.  Thus,  at 
Los  Angeles  the  mean  winter  temperature  is  57' 1°,  at  Funchal, 
59-9°;  the  mean  summer  temperatures  being  in  each  case  677°. 
The  daily  range — in  winter,  21-2°  at  Los  Angeles — is,  however, 
considerably  greater.  The  brilliant  sunshine  enjoyed  by  the 
Californian  resorts  is  also  demonstrated  by  the  records,  which 
show  that  as  much  as  3,219  hours  were  recorded  during  the 
year,  1,457  o^  which  occurred  in  winter.  For  comparison,  we 
may  add  that  the  yearly  totals  at  Bournemouth,  Torquay,  and 
Hastings  amount  to  1,717,  1,731,  and  1,783  hours;  and  for  the 
six  winter  months,  572,  568,  and  580  respectively.  The  rain- 
fall at  Los  Angeles  is  only  15-6  inches,  and  the  number  of 
rainy  days  throughout  the  year  not  more  than  forty.  A  glance 
at  the  table  on  p.  643,  and  at  the  more  detailed  tables  printed 
in  the  appendix  to  the  last  edition  of  this  work,  will  show 


668  DISEASES   OF  THE  LUNGS   AND   VLEVRM 

how  favourably  these  figures  compare  with  those  of  other 
stations. 

With  a  genial  climate  of  this  nature,  the  health  resorts  of 
Southern  California  will  be  found  to  afford  winter-quarters 
suitable  for  those  phthisical  patients  with  low  vitaHty,  or  with 
disease  too  advanced  for  the  American  altitudes,  or  for 
whom  those  chmates  are  for  other  reasons  undesirable. 
Among-  the  resorts  we  may  mention  Sa?i  Diego  and  Santa 
Barbara,  on  the  Pacific  coast,  Pasadena,  some  twenty  miles 
inland,  not  far  from  Los  Angeles,  and  Sierra  Madre,  in  the 
same  region.  At  Monrovia,  sixteen  miles  from  Los  Angeles, 
there  is  a  well-known  private  sanatorium. 

These  stations  are  too  far  removed  from  England  for  tem- 
porary resorts,  but  are  available  for  American  invalids,  some 
of  whom  after  their  recovery  may  decide  to  make  their  per- 
manent residence  in  such  localities,  and  perhaps  find  light  and 
satisfactory  outdoor  occupation  in  connection  with  fruit- 
farming-  and  the  cultivation  of  oranges  and  lemons,  for  which 
California  is  famed.*^ 

Spring  (March,  April,  and  May). — Our  islands  can  boast  of 
but  few  localities  suitable  for  chest  invahds  during  spring. 
There  are,  however,  numerous  nooks  and  corners  with  sunny 
exposure  and  protection  from  cold  winds,  where  on  porous 
soil  and  at  a  moderate  elevation  residences  exist  or  might  be 
built,  singly  or  in  small  groups,  suitable  for  invalids  who  are 
unwilling  or  unable  to  go  farther.  At  some  of  our  seaside 
places,  such  as  Bournemouth,  the  Isle  of  Wight,  Torquay,' 
St.  Mary  Church,  Tenby  or  Grange,  sheltered  spots  can  be 
found.  Bridge  of  Allan,  by  Stirling,  N.B.,  is  a  spring  station 
of  considerable  merit,  and  here,  on  the  southern  slope  of  the 
hill,  protected  from  the  north  and  east,  are  houses  and  a  well- 
found  hydropathic  establishment  with  sheltered  walks. 

Throughout  the  Continent  the  same  difficulty  presents  itself 
to  a  greater  or  less  degree  with  regard  to  the  avoidance  of 
irritating  cold  spring  winds.  With  the  exception,  however, 
of  this  occasional  drawback,  most  felt  during  February  and 
March,  the  whole  Riviera  is  at  its  best  during  the  spring 
season.  Parts  of  Mentone,  Beaulieu,  Monte  Carlo,  Bor- 
dighera,  San  Remo,  and  some  sheltered  portions  of  Hy^res, 
are  the  most  protected;  but  it  is,  perhaps,  scarcely  wise,  on 


ON  CLIMATIC  CHANGE  669 

account  of  occasional  cold  winds,  to  shift  quarters  that  are 
otherwise  suitable.  Grasse  (1,000  feet),  a  bracing  hill  suburb 
of  Cannes,  nine  miles  from  the  coast,  is  a  good,  late  spring 
resort.     Les  Avants,  above  Montreux,  is  also  protected. 

Many  patients  who  have  spent  the  winter  at  the  Riviera  are 
tempted  at  this  season  to  move  on  to  Florence  (where,  how- 
ever, the  spring  winds  are  much  felt)  or  to  Rome.  In  the 
case  of  pulmonary  invalids  this  is  not  to  be  sanctioned. 

Madeira,  the  Canaries,  and  Algiers  are  not  affected  by 
severe  spring  winds;  but  the  latter  place  becomes  too  warm 
for  residence  in  the  later  spring.  Arcachon  and  Pau  are  fairly 
good  spring  climates.  At  this  season  of  the  year  a  voyage  to 
the  West  Indies  may  often  be  recommended  for  convalescents 
from  acute  chest  diseases. 

Summer  {June,  July,  and  August). — In  the  summer  months 
the  travelled  and  tired  invaHd  will  generally  do  best  to  return 
to  his  home  and  famiUar  haunts,  friends,  and  diet.  June  is  a 
favourable  month  for  visiting  certain  health  resorts  and  baths, 
such  as  Ems,  Aix-les-Bains,  Aix-la-Chapelle,  Allevard-les- 
Bains,  Royat,  Mont  Dore,  Eaux  Bonnes,  but  chiefly  for  the 
treatment  of  special  throat  or  other  symptoms,  to  be  incident- 
ally alluded  to  elsewhere. 

After  a  period  of  treatment,  such  as  we  have  sketched  out, 
the  patient  may  have  regained  his  health  sufficiently  to  allow 
of  his  return  to  work.  We  have  pointed  out  in  a  former 
chapter  (p.  622)  that  it  is  better  for  him,  if  he  has  been 
a  city  dweller  before,  to  alter  the  environment  and  to  live  in 
future  in  the  country  or  some  small  county  town.  If,  how- 
ever, his  occupation  must  be  carried  out  in  a  large  city,  then 
he  should  live  out  of  town  or  in  some  healthy  suburb.  For 
those  whose  work  lies  in  London,  we  may  recommend  such 
localities  as  Hampstead,  Highgate,  Golder's  Green  or 
Hendon.  In  the  case  of  those  who  can  live  farther 
afield,  the  neighbourhood  of  Croydon,  Purley,  W oldingham, 
Oxted  and  Tamworth  may  be  recommended  amongst  others, 
or  the  Chilterns  in  the  neighbourhood  of  Chorley  Wood, 
Great  Missenden,  and  Amersham.  We  have  also  known  not 
a  few  patients  derive  benefit  from  living  at  Westcliff-on-Sea 
or  Southend,  where  long  week-ends  may  be  enjoyed,  and 
whence  there  is  a  good  train  service  to  London. 


670  DISEASES   OF  THE  LUNGS   AND   PLEUR/E 

In  choosing  a  residence  regard  must  be  had  to  dryness  of 
locality,  abundant  sunshine,  and  protection  from  prevalent 
winds.     Trees  must  not  be  in  too  close  proximity  to  the  house. 


REFERENCES. 

'■  For  a  consideration  of  the  meteorological  data  bearing  on  these 
differences,  see  the  article  on  "  The  Climate  of  the  Midland  Counties,"  by 
P.  Horton-Smith  (Hartley),  M.D.,  in  The  Climate  and  Baths  of  Great 
Britaitz,  vol.  ii.,  p.   119.     London,  1902. 

^  See  "  What  Influence  has  Climate  on  the  Treatment  of  Consumption 
and  how  far  can  Cases  be  Grouped  for  Treatment  in  Certain  Climates?" 
by  C.  Theodore  Williams,  M.D.,  Transactions  of  the  British  Congress  on 
Tuberculosis,  vol.  iii.,  p.  14.     London,  1901. 

^  "  Treatment  of  Tuberculosis  at  Sea,"  The  Lancet,  1909,  vol.  i.,  p.  1188. 

*  For  a  consideration  of  the  differences  in  climate  between  these  four 
stations  see  the  meteorological  data  given  in  "  A  Clinical  Lecture  on  Mitral 
Regurgitation,"  by  P.  Horton-Sm^ith  (Hartley),  M.D.,  The  Clinical  Journal, 
February  12,  1902,  p.  271. 

*  The  Influence  of  Climate  in  the  Prevention  and  Treatment  of  Pulmonary 
Consumption,  by  Charles  Theodore  Williams,  M.D.     London,  1877. 

"  For  a  more  detailed  description  of  the  climate  and  of  the  health  resorts 
of  California  we  must  refer  the  reader  to — 

(i)   "  The  Health  Resorts  of  the  United  States,"  by  S.   Edwin  Solly, 
M.D.,  in  Dr.  Hale  White's  Textbook  of  Pharmacology  and  Therapeu- 
tics, p.  958.     London,  1901. 
{2)  A  Handbook  of  Climatic  Treatment ,  by  William  R.  Huggard,  M.D,, 
p.  266.     London,  1906. 


CHAPTER  XLVII 

TREATMENT  OF  PULMONARY  TVBERCVLOSIS— (Continued) 

Acute  First-Stage  Cases — Active  Softening  and  Formation  of 

Cavities — Summary. 

Acute  First  Stage. — In  the  active  periods  of  the  more  acute 
forms  of  tuberculosis,  so  long  as  there  are  signs  of  recent 
consolidation,  with  maintained  pyrexia,  rapid  pulse,  trouble- 
some cough  and  expectoration,  the  latter  perhaps  blood- 
stained, patients  require  complete  rest,  careful  nursing,  and 
treatment  under  open-air  conditions,  until  the  acute  period 
of  the  illness  subsides.  At  this  time  the  patient  is  receiving 
discharges  of  bacillary  toxines  into  his  blood;  his  antitoxic 
reaction  is  strained,  and  his  phag"ocytic  powers  overwhelmed 
by  the  heavy  doses  of  the  poison.  The  hurried  action  of  the 
heart  and  breathing  and  frequent  cough  all  bear  testimony  to 
the  necessity  for  quietude;  any  movement  or  change  from 
passive  recumbency  still  further  quickens  the  breathing,  raises 
the  blood-pressure,  and  helps  to  waft  into  the  blood-current 
the  poisons  which  are  being  locally  elaborated. 

The  diet  should  be  nutritious  and  plentiful,  and  two  or 
three  pints  of  milk  should  be  given  each  day,  in  addition  to 
such  light  solid  food  as  can  be  borne;  for  it  generally  hap- 
pens that  the  patient  has  emaciated  and  is  considerably  below 
his  normal  height-weight  ratio.  Stimulants,  unless  the  appe- 
tite fails,  are  as  a  rule  better  avoided.  The  secretions  must 
be  cleared,  and  in  cases  where  the  circulation  is  much  quick- 
ened and  the  skin  dry  and  hot  an  effervescing  saline  mixture 
may  be  given  every  four  or  six  hours.  Presently  an  alkaline 
mixture  should  be  substituted,  and  to  it  may  be  added,  when 
the  temperature  has  abated,  hypophosphite  of  soda,  to  be 
taken  three  times  in  the  twenty-four  hours.     When  pain  is 

671 


6/2  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

complained  of,  some  epispastic  solution  should  be  painted 
over  the  part  affected,  or  in  acute  cases  two  or  three  leeches 
applied. 

The  night  perspirations  at  this  early  period  of  the  disease 
are  rarely  of  a  severe  character,  and  especially  is  this  the  case 
since  the  introduction  of  the  open-air  regime,  and  it  is  wise 
as  a  rule  not  to  check  them  by  any  drug  treatment.  If  the 
temperature  at  night  range  high,  it  may  be  moderated  by 
tepid  sponging  and  quinine,  and  half  a  grain  of  opium  may 
be  given  if  the  cough  causes  restlessness.  In  other  cases  a 
cachet  containing  7  grs.  of  aspirin  and  3  grs.  of  phenazone 
will  check  the  fever  and  soothe  the  erethism  with  which  it  is 
attended.  Under  such  treatment  the  pyrexia  will  in  favourable 
cases  subside,  or  at  least  be  reduced  to  a  moderate  evening 
rise  of  temperature  to  99°  or  100°,  which  may  persist  for  some 
considerable  time. 

Restraint  of  the  movements  of  the  chest  over  the  affected 
area  by  lung  spHnts  and  other  appliances  has  been  suggested ; 
but  the  normally  slight  expansile  movements  of  the  apices 
become  further  restricted  in  disease  without  mechanical  aid, 
and  the  object  of  rest  to  the  part  is  sufficiently  secured  by 
insisting  on  that  freedom  from  effort  or  exercise  which  shall 
secure  the  most  complete  quietude  possible  to  the  respiratory 
and  circulatory  systems  during  the  first  febrile  period  of  the 
disease. 

It  is  of  great  importance  to  relieve  disturbing  night  cough, 
a  symptom  distressing  to  the  patient,  and  destructive  of  that 
functional  rest  of  the  lung  which  we  are  desirous  to  secure. 
The  following  mixture  may  be  usefully  prescribed  for  this 
symptom :  Nepenthe  3  i.,  Codeinae  gr.  i.,  Syrupi  Chloral 
Hydratis  3vi.,  Mucilaginis  Acacise,  gi.ss.,  Syr.  Pruni  Vir- 
ginianas  gss.,  Aquam  Chloroform!  ad  5vi.,  of  which  one  table- 
spoonful  should  be  sipped  from  the  spoon  at  bedtime,  and 
half  a  dose  similarly  taken  once  or  twice  in  the  nig-ht. 

It  will  often  be  observed  that  the  cough  remains  trouble- 
some, while  the  pulmonary  signs  are  greatly  improving,  and 
all  secretion  sounds  rapidly  drying  up.  This  irritable  cough, 
which  is  so  frequently  attendant  upon  the  subsidence  of  pul- 
monary disease,  should  be  checked  by  the  patients  themselves 
as  much  as  possible.  This  they  can  do  to  a  great  extent,  but 
they  may  be  assisted,  if  necessary,  to  secure  rest  at  night  by 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  673 

some  such  mixture  as  we  have  mentioned  above,  or  with  the 
help  of  one  or  two  morphine  and  ipecacuanha  lozenges.  The 
morning  cough  in  these  cases,  and,  indeed,  in  many  others, 
is  the  most  troublesome.  It  is,  however,  the  natural  conse- 
quence of  a  good  night's  rest,  and  should  never  be  checked 
by  a  sedative,  since  the  matters  suitable  only  for  elimination, 
if  retained,  considerably  impede  respiration,  become  highly 
irritating,  and  set  up  further  inflammatory  and  specific  trouble 
in  the  lungs.  A  cup  of  hot  coffee,  tea  or  milk,  taken  before 
rising,  will  greatly  facilitate  expectoration.  If  this  does  not 
suffice,  a  small  dose  of  ether  and  ammonia  should  be  given, . 
or  if  the  phlegm  be  viscid  and  difficult  to  cough  up,  a  mixture 
containing  Ammonium  Carbonate  gr.  iii..  Sodium  Bicarbonate 
gr.  vii..  Spirit  of  Chloroform  nix.,  distilled  water  to  half  an 
ounce,  to  be  taken  in  an  equal  quantity  of  hot  water  on 
first  waking.  The  old-fashioned  remedy  of  rum  and  milk 
taken  early  in  the  morning  is  also  useful  for  this  purpose;  a 
dessert-spoonful  of  rum  to  a  claret  glass  of  warm  milk  being 
sufficient. 

On  the  subsidence  of  fever,  or  in  more  serious  cases  its 
abatement  to  an  evening  rise  of  temperature  only,  cod-Hver 
oil  may  be  given,  and  some  tonic  containing  arsenic,  iron, 
mineral  acid  or  alkaline  bitter,  as  the  general  and  particular 
features  of  the  case  may  suggest.  In  many  cases  such  tonics 
are  not  indicated,  and  in  any  case  it  is  rarely  necessary  to 
give  more  than  two  doses  a  day,  at  times  carefully  specified 
with  regard  to  the  meals,  according  to  the  drugs  prescribed. 

The  question  of  allowing  the  patient  up  and  of  permitting 
exercise  may  now  be  considered;  but  as  a  rule  no  relaxa- 
tion should  be  permitted  until  both  morning  and  evening 
temperatures  have  been  normal  for  some  two  or  three 
weeks.  He  may  then  be  promoted  to  a  couch  on  the  balcony, 
or  in  the  Liegehalle  or  garden  shelter,  and  finally  the  effect 
of  graduated  exercise  will  be  observed.  Perhaps  the  best 
way  to  begin  is  to  allow  a  quiet  walk  of  five  minutes  out  of 
the  hour,  until  the  required  amount,  be  it  ten,  fifteen,  twenty, 
or  more  minutfes  of  daily  exercise,  has  accumulated.  The 
patient  is  now  in  a  condition  suitable  for  removal  to  a  sana- 
torium, where  he  will  have  the  advantage  of  that  constant 
medical  supervision  which  is  so  desirable  in  the  treatment  of 
his  case,  and  especially  necessary  in   graduating  the   daily 

43 


6/4  DISEASES   OF  THE  LUNGS   AND   PLEURA 

amount    of    exercise    which    may    be    safely  permitted   (see 
p.  606). 

The  Uses  and  Administration  of  Cod-Liver  Oil. — The  advo- 
cacy of  the  use  of  cod-liver  oil  in  phthisis  by  the  late  Drs. 
C.  J.  B.  WiUiams  and  Hughes  Bennett  gained  for  this  remedy 
a  recognised  value  second  to  none  other  in  the  treatment  of 
the  disease,  and  from  the  statistics  of  the  Brompton  Hospital, 
pubhshed  in  the  First  Medical  Report"^  (1849),  as  well  as  from 
the  results  obtained  in  private  cases  and  recorded  by  Dr.  Theo- 
dore Williams,^  there  can  be  no  doubt  that  at  the  time  of  its 
introduction,  and  as  an  adjuvant  to  the  methods  of  treatment 
then  in  vogue,  it  was  of  great  value.     At  the  present  day, 
when,  by  a  more  bracing  regime  and  a  more  generous  diet, 
the  tissue  metabolism  of  the  patient  is  already  being  stimu- 
lated to  the  full,  its  value  is  less  marked.     It  is,  however,  still 
indicated  when  the   patient  is  below  weight  and   does  not 
respond  well  to  ordinary  treatment,  and  it  is  especially  useful 
among  the  poor,  when  the  diet  is  not  all  that  can  be  desired. 
Cod-liver    oil    has    been    sometimes    regarded    rather    as 
a    food    than    a    medicine,    and    its    easy    assimilation    and 
absorption  render  it  no   doubt  a  valuable  nutrient.     In  the 
recent  shortage  of  butter  and  cream  and  other  fatty  foods, 
cod-liver  oil  alone  or  combined  with  malt  extract  has  been  a 
useful  resource.     In  some  way,  also,  cod-liver  oil  appears  to 
affect  favourably  the  patient's  metabolism  in  a  manner  that 
cannot  be  altogether  accounted  for  by  the  quantity  taken, 
assuming  it  to  be  only  a  food — one  to  four  teaspoonfuls  two 
or  three  times  a  day  being  the  average  dose.     The  observa- 
tions of  Dr.  Wells,^  which  have  since  been  confirmed,  suggest 
that  in  addition  to  its  easy  absorption,  it  possesses  the  power 
of  "increasing  the  absorption  of  the  other  fats  of  the  foods 
to  a  marked  degree,"  and  also  leads  to  a  diminished  excretion 
of  nitrogen,  and  thus  to  an  increased  storing  up  of  proteid 
within  the  body.     It  would  seem  also  from  the  experiments 
of   Drs.    Williams   and   Forsyth*   that   the   unsaturated   fatty 
acids,  of  which  the  oil  is  almost  entirely  composed,  tend  to 
produce  a  disintegration  of  the  waxy  envelope  which   sur- 
rounds the  tubercle  bacillus,  thus  possibly  leading  to  its  more 
easy  destruction  in  the  blood  and  tissues.    Cod-liver  oil  would 
appear  further  to  have  a  special  power  of  aiding  the  regenera- 
tion and  nutrition  of  the  cells  lining  the  respiratory  tract,  and 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  675 

to  be  of  great  service  in  clearing  up  the  intercurrent  catarrhs 
which  are  so  frequent  in  those  prone  to  tubercle.  To  its 
value  in  chronic  bronchitis  we  have  already  alluded  (see  p.  193). 

The  best  time  for  taking-  cod-liver  oil  is  soon  after  meals, 
when  the  stomach  is  occupied  by  food  in  a  condition  prepared 
for  escape  through  the  pylorus,  for  it  is  beyond  the  pylorus 
that  the  oil  becomes  absorbed;  but  some  patients  will  in  prac- 
tice be  found  better  able  to  assimilate  the  remedy  at  other 
times.  In  children,  and  sometimes  in  adults,  the  syrupus  ferri 
phosphatis  co.  of  the  B.P.C.,  or  steel  wine  are  excellent 
vehicles,  and  various  other  agreeably  flavoured  tonics  may  be 
combined  with  the  oil,  such  as  quinine  wine  with  a  little  hypo- 
phosphite  of  soda  or  lime,  or  phosphoric  acid  and  strychnia 
with  syrup  of  orang'e. 

Certain  additions  may  sometimes  with  advantage  be  made 
to  cod-liver  oil :  thus,  a  drop  of  creosote  or  too  grain  of 
strychnia  (Williams)  are  valuable  correctives.  In  a  few  cases 
it  will  also  be  found  that  the  addition  of  an  alkali  by  emulsi- 
fying the  oil  will  enable  it  to  be  better  borne  and  absorbed;* 
and  there  are  now  many  excellent  and  comparatively  palatable 
emulsions  of  cod-liver  oil  made  in  combination  with  malt 
extracts.  Of  these  a  simple  emulsion  of  oil  and  malt  extract 
in  equal  parts  can  usually  be  well  borne,  a  dessert-spoonful 
or  more  two  or  three  times  a  day  being-  prescribed.  The 
Emulsio  Olei  Morrhuse  Co.  of  the  B.P.C.  contains  50  per 
cent,  of  oil,  and  is  an  elegant  preparation  which  may  be 
recommended  for  persons  of  delicate  digestion. 

The  most  favourable  periods  for  giving  oil  are  the  apyrexial 
intervals  of  phthisis.  In  small  doses,  however,  the  remedy 
can  sometimes  be  taken  with  advantage,  if  not  during  the 
period  of  continued  fever,  at  least  during  the  more  prolonged 
hectic  of  the  disease. 

If  for  any  reason  cod-liver  oil  cannot  be  taken,  trial  may 
be  made  of  Sodium  Morrhuate,  a  preparation  lately  introduced 
by  Sir  Leonard  Rogers,^  and  containing  the  sodium  salts  of 
the  unsaturated  fatty  acids  of  which  cod-liver  oil  is  com- 
posed. Small  doses,  commencing  with  \  c.c.  of  the  3  per  cent, 
solution,  and  increasing  by  2-4  minims  at  each  injection  to 
2  c.c,  are  given  subcutaneously  two  or  three  times  a  week. 

*  Brompton  formula  :  Mist.  Olei  Morrhuae  Preparata.  ^.  Olei  Morrhuaj 
5vi.,  Liq.  Ammoniae  Fort,  itiii.,  Olei  Cassiae  nii.,  Syrupi  3ii.     Dosis  3ii. 


6/6  DISEASES   OF   THE   LUNGS    AND   PLEURA 

Intravenous  injections,  beginning  with  ^  c.c,  are  then  recom- 
mended, and  should  be  cautiously  increased.  Should  a  febrik 
reaction  occur  the  dose  should  be  diminished.  We  have  tried 
the  preparation  by  subcutaneous  injection  and  seen  benefit 
result,  but  have  not  ourselves  given  it  intravenously. 

Creams  and  fats  may  be  also  prescribed.  A  piece  of 
mutton  suet  allowed  slowly  to  dissolve  in  a  tumbler  of  milk, 
warmed  by  standing  on  the  hob  or  in  a  slow  oven,  is  an  old- 
fashioned  remedy  for  phthisis;  the  milk  thus  treated  should 
be  filtered  through  muslin  before  being  taken.  Olive  oil 
taken  alone,  or  with  salads  or  sardines,  is  an  imperfect  sub- 
stitute for  cod-liver  oil. 

Of  general  tonic  remedies  in  the  early  periods  of  phthisis, 
arsenic  is  one  of  the  most  valuable.  The  arseniate  of  iron  or 
small  doses  of  arsenious  acid  may  be  given  in  pilules  with 
food  twice  a  day.  The  late  M.  Jaccoud  recommended  t'o  grain 
of  arsenious  acid  to  be  taken  in  pill  form  at  the  commence- 
ment of  two  principal  meals,  increasing  the  dose  each  week 
by  two  pilules,  until  six,  eight,  or  ten  are  taken  daily;  this 
treatment  being-  continued  for  two  or  three  months  unless 
signs  of  intolerance  of  the  drug  are  shown.  After  this  period 
the  dose  should  gradually  be  diminished.  This  remedy  is 
especially  valuable  in  cases  in  which  iron  is  not  well  borne. 
If  under  the  arsenical  treatment  appetite  fails,  the  tongue 
becomes  coated,  digestion  painful,  or  the  bowels  relaxed,  it 
must  be  at  once  restricted  or  withdrawn. 

Unless  specially  indicated,  strychnia  and  quinine  are  of  no 
particular  service  at  this  period.  The  hypophosphites  are  of 
undoubted  value,  and  also  iron  in  small  doses  and  for  short 
courses. 

Period  of  Active  Softening  and  Formation  of  Cavities. — Dur- 
ing this  period  the  particular  symptoms  to  be  regarded  are : 
(i)  pyrexia;  (2)  nervous  prostration  and  bodily  exhaustion; 
(3)  certain  special  symptoms — viz.,  wasting,  anorexia,  night- 
sweats,  cough  and  expectoration,  haemoptysis  and  intercurrent 
pleurisies. 

Pyrexia. — The  fever  at  this  period  of  phthisis,  often  hectic 
in  type,  is  probably,  as  we  have  seen  (p.  467),  dependent  in 
most  cases  upon  the  active  growth  of  the  tubercle  bacillus, 
and  the  absorption  of  the  tuberculous  toxines  so  found.  In  a 
smaller  proportion  of  cases  true  secondary  infections  are  pre- 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  677 

sent,  and  the  organisms  responsible  take  their  share  in  the 
production  of  the  pyrexia. 

With  regard  to  the  treatment  of  such  cases,  we  must  re- 
member that  the  growth  of  the  tubercle  bacillus  and  of  the 
pyogenic  and  other  org'anisms,  with  which  it  may  be  asso- 
ciated, is  most  favoured  at  the  noiTnal  body  temperature,  and 
that  the  presence  of  fever  may  not  improbably  be  regarded 
as  to  some  extent  a  protective  factor  tending  to  inhibit 
activity  and  growth.  It  is  probable  also  that  phagocytosis 
is  more  active,  and  that  protective  bodies,  such  as  antitoxins, 
bacteriolysins  and  agglutinins,  are  produced  more  readily 
when  a  moderate  degree  of  fever  is  present  than  at  the  normal 
temperature  of  the  body."  Whilst  the  growth  of  the  bacillus 
and  attendant  organisms  is  most  favoured  by  a  normal  tem- 
perature, the  higher  ranges  of  temperature,  on  the  other  hand, 
are  associated  with  a  neg'ative  phase,  during'  which  the 
phagocytic  and  other  protective  functions  of  the  blood  are 
depressed. 

Our  treatment  of  fever,  therefore,  must  be  cautious,  and 
should  be  directed  chiefly  to  heightening  the  resisting  power 
of  the  patient  by  means  of  a  generous  diet  and  the  stimulating 
effect  of  fresh  air,  thus  enabling  him  to  form  additional  pro- 
tective substances  and  to  check  the  growth  of  the  tubercle 
bacillus  and  of  other  organisms  which  may  be  associating 
themselves  in  its  activity.  This  effort  on  the  part  of  the 
patient  may  be  assisted  by  certain  drugs,  such  as  arsenic  and 
iodine. 

Arsenic  itself  cannot  be  given  in  these  cases  in  sufficient 
doses  to  diminish  the  temperature  in  any  striking  degree,  but 
it  has  a  marked  influence  upon  some  of  the  most  distressing 
symptoms  attendant  upon  the  fever;  and  it  sometimes  in  a 
striking  manner  improves  the  g'eneral  condition  of  the  patient. 
This  drug  is  most  indicated  in  those  cases  in  which  daily 
recurring  chills  are  complained  of.  Three  to  five  drops  of  the 
liq.  arsenicalis  or  of  the  arseniate  of  soda  solution,  or  gr.  ~ 
to  gr.  I  of  the  arseniate  of  iron  three  times  a  day,  will  often 
suffice  to  prevent  the  recurrence  of  these  chills.  Arsenic  must 
be  given  with,  or  immediately  after,  meals. 

Another  preparation  of  arsenic  which  we  often  prescribe, 
and  which  is  less  toxic  and  can  therefore  be  administered  in 
larger  doses,   is   the   cacodylate   of   soda   (sodium   dimethyl- 


6/8  DISEASES   OF   THE  LUNGS   AND   PLEURA 

arseniate).  This  may  be  given  by  the  mouth  in  doses  of  half 
a  grain  three  times  a  day,  or,  better,  by  hypodermic  injection, 
the  patient  receiving  siibcutaneously  each  day  for  fourteen 
days  a  single  f-grain  dose,  dissolved  in  i  c.c.  (17  minims)  of 
sterilised  water.  An  interval  of  ten  days  should  then  be 
allowed  before  reverting  to  the  injections.  During  the  treat- 
ment due  observation  should  be  kept  upon  the  knee-jerks  and 
the  fields  of  vision  to  insure  that  no  adverse  effects  are  being 
produced  upon  the  nervous  system,  though  we  have  never 
known  such  to  occur.  The  cacodylate  of  soda  appears  to  us 
to  be  more  effective  than  simple  arsenic,  and  when  the  fever 
has  not  been  severe  we  have  several  times  known  it  to  abate, 
and  the  temperature  to  become  normal  after  two  or  three 
courses  of  injections.  In  other  cases,  especially  when  there 
has  been  a  syphilitic  taint,  we  have  obtained  benefit  from 
injections  of  neo-salvarsan.' 

Should  arsenical  treatment  fail,  or  the  patient  be  averse  to 
the  injections,  we  should  advise  that  trial  be  made  of  the 
intensive  iodine  treatment,  introduced  by  Dr.  David  Curle.^ 
This  treatment  consists  in  prescribing  20  grains  of  Potassium 
Iodide  in  half  a  pint  of  water  after  breakfast,  and  four  hours 
later  an  ounce  of  Aqua  Chlori  in  half  a  pint  of  freshly  pre- 
pared and  sweetened  lemonade,  thus  effectually  masking  the 
nauseous  taste  of  the  chlorine.  The  dose  of  chlorine  water  is 
repeated  at  intervals  of  two  hours  until  three  doses  have  been 
given,  and  after  two  or  three  weeks  a  fourth  dose  may  be 
added.  The  chlorine  liberates  iodine  from  the  potassium 
iodide  in  the  blood,  and  any  beneficial  effect  is  thought  to  be 
due  to  the  antiseptic  action  of  the  nascent  iodine  thus  pro- 
duced. Should  symptoms  of  iodism  manifest  themselves, 
30  grains  of  Sodium  Bicarbonate  should  be  given  every  two 
hours,  and,  if  the  symptoms  continue,  the  treatment  should  be 
stopped;  but  we  have  not  often  observed  this  complication. 

We  have  tried  this  method  on  many  occasions,  and  though 
we  have  never  observed  any  sudden  fall  of  temperature  to  fol- 
low its  use,  we  have  in  not  a  few  cases  of  moderate  pyrexia 
observed  a  gradual  lowering  of  the  fever,  and  sometimes  its 
complete  subsidence,  after  some  weeks  of  treatment. 

During  this  hectic  period  iodoform,  creosote,  and  tar  have 
been  recommended  for  internal  administration  on  account  of 
their  antiseptic  properties.     We  have  ourselves  found  them 


TREATMENT  OF   PULMONARY  TUBERCULOSIS  679 

of  more  value  in  the  apyrexial  period  (see  p.  687).  When  there 
is  much  local  disturbance  of  stomach  and  upper  bowel,  how- 
ever, small  doses  of  creosote,  in  combination  with  opium,  are 
sometimes  of  considerable  service. 

Antipyretics  must  be  employed  with  care,  and  should  be 
prescribed  with  the  idea  of  moderating'  fever  when  excessive, 
rather  than  of  suppressing  it  altogether.  It  sometimes  hap- 
pens, however  that  the  good  effect  upon  the  temperature  per- 
sists after  the  discontinuance  of  the  drug.  The  following 
antipyretic  remedies  may  be  considered : 

(a)  Quinine. — In  from  three  to  five  grain  doses,  taken  in 
milk  and  between  meal-times,  quinine  is  often  of  value  in  con- 
trolling hectic  and  in  sustaining-  the  patient.  A  tablespoonful 
of  whisky  may  often  with  advantage  be  added. 

(b)  Phenazone,  antifehrin,  phenacetin,  and  allied  drugs  of 
well-known  power  in  reducing  temperature,  are  to  be  used  in 
phthisis  with  great  caution,  and  in  carefully  calculated  doses 
prescribed  at  definite  times  with  a  view  to  moderating  exces- 
sive peaks  of  temperature.  In  many  cases  they  cause  con- 
siderable nervous  depression,  with  profuse  sweating",  and 
sometimes  vomiting;  in  others  they  merely  postpone  the 
pyrexial  rise  to  a  later  period  of  the  day,  and  weaken  the 
control  of  the  nerve  centres,  thus  exaggerating  pyrexial  fluc- 
tuations. In  small  doses,  however,  such  as  five  grains  of 
phenazone,  or  two  to  three  grains  of  phenacetin,  in  combina- 
tion with  quinine,  salicin  or  aspirin,  these  drugs  are  some- 
times of  assistance. 

(c)  Cryogenin  (meta-benzamine-semicarbazide)  is  also  of 
value  in  this  direction.  It  is  best  given  in  cachet  form  in 
doses  of  seven  or  ten  grains,  about  three  hours  before  the 
maximum  daily  temperature  is  reached,  and  is  often  success- 
ful in  producing  a  decided  diminution  of  fever.  No  untoward 
symptoms  seem  to  accompany  its  use,  though,  as  with  others 
of  these  drugs,  its  effect  is  too  often  temporary.^ 

The  evening  temperature  can  sometimes  be  sufficiently 
moderated  without  medication  by  the  employment  of  tepid 
sponging  with  a  solution  of  dilute  acetic  acid  one  part,  water, 
at  a  temperature  of  about  85°,  six  parts,  and  eau-de-Cologne 
I  part.  As  an  adjuvant  to  other  remedies,  especially  when 
there  are  night-sweats',  this  apphcation  is  of  value. 


680  DISEASES   OF  THE  LUNGS   AND  PLEURA 

In  the  comparatively  rare  cases  in  which  a  true  secondary 
infection  is  present  (see  p.  467),  if  the  fever  continues  in  spite 
of  treatment,  a  cautious  attempt  may  be  made  to  check  its 
progress  by  means  of  an  appropriate  vaccine.  We  have  not, 
however,  observed  much  benefit  from  this  Hne  of  treatment. 

Acute  cases  of  the  kind  which  we  are  considering,  provided 
the  disease  is  restricted  to  one  lung,  are  sometimes  greatly 
benefited  by  the  induction  of  an  artificial  pneumothorax,  a 
method  of  treatment  which  we  shall  consider  in  a  later  chap- 
ter (p.  719).  This  form  of  treatment  should  always,  there- 
fore, be  borne  in  mind,  and  must  be  carefully  considered,  as 
soon  as  it  has  been  shown  that  the  pyrexia  is  not  yielding  to 
more  ordinary  methods  of  treatment. 

Cough  :  its  Local  and  General  Treatment. — Except  for 
cases  in  which  throat  symptoms  are  prominent,  sprays  are 
of  Httle  value,  since  it  is  very  doubtful  whether  they  penetrate 
beyond  the  larynx  or  main  bronchi. 

There  is  no  doubt,  however,  that  by  the  inhalation  of  the 
dry  vapours  of  volatile  antiseptics  much  advantage  may  be 
gained  in  this  stag'e  of  the  disease.  The  effect  of  such  inhala- 
tions is  to  lessen  expectoration  and  to  relieve  cough;  and  one 
of  their  chief  functions  is  to  diminish  the  necessity  for  cough 
mixtures."  Certainly  the  cough  linctus  treatment  of  this 
eliminative  period  of  phthisis,  by  continually  lulling  cough 
and  deranging  stomach,  is  the  very  worst  that  could  be 
devised.  Our  great  objects  are  to  get  rid  of  the  effete  pro- 
ducts of  caseous  liquefaction  and  suppuration,  and  to  keep  the 
pus-secreting  surface  as  disinfected  as  possible  without  harm- 
ing the  patient  in  the  process.  The  cavity  contents  are,  it  is 
to  be  remembered,  in  contact  with  living  tissue,  which  has 
a  retarding  influence  upon  bacterial  activity;  and  it  is  from 
this  point  of  view  that  we  look  to  general  tonic  and  hygienic 
measures  as  operative  in  aid  of  our  more  special  medication. 

The  majority  of  patients  find  close  naso-oral  respirators 
irksome,  but  can  wear  the  more  open  and  lighter  pattern 
devised  by  the  late  Dr.  Burney  Yeo  for  a  longer  time  and 
with  less  fatigue.  The  pattern  long  in  use  at  the  Brompton 
Hospital  is  of  this  type,  and  consists  of  perforated  zinc,  bound 
round  the  edge  where  in  contact  with  the  face  with  chamois 
leather.  A  small  receptacle  is  provided  for  the  cotton-wool, 
which  must  be  moistened  with  the   solution  for  inhalation. 


TREATMENT  OF  PULMONARY   TUBERCULOSIS  68 1 

This  respirator  is  inexpensive,  and  may  be  obtained  from 
Messrs.  Maw  and  Sons.  Other  forms  are  those  of  Coghill 
and  Roberts. 

A  good  inhalant  consists  of  a  mixture  of  the  following : 
Tincture  of  Iodine  3i.,  Liquefied  Carbolic  Acid  3ii.,  Creosote  3ii., 
Spirit  of  Ether  3i.,  and  Spirit  of  Chloroform  3ii.  We  have  also 
found  three  drachms  of  eucalyptol  or  olei  pini  sylvestris  to 
the  ounce  of  rectified  spirit,  or  spirit  of  chloroform,  a  good 
combination :  twenty  drops  on  the  wool  of  the  respirator,  to 
b-e  used  for  half  an  hour  to  an  hour  or  longer,  after  the  first 
morning  expectoration,  in  the  middle  day  and  in  the  evening. 
If  the  cough  be  troublesome,  one  drachm  of  oil  of  bitter 
almonds  may  be  added  to  the  one-ounce  solution,  and  double 
strength  spirit  of  chloroform  used  as  the  solvent.  If  the 
patient  be  able  by  assuming  a  dependent  posture  and  by  a 
determined  effort  more  completely  to  clear  the  cavities  before 
the  use  of  the  respirator,  it  is  well  to  do  so.  This  must  be 
decided  at  the  discretion  of  the  doctor.  In  some  cases  the 
respirator  may  be  worn  almost  constantly,  such  "continuous 
inhalation"  of  antiseptic  vapour  being  thoug"ht  by  the  late 
Dr.  Lees  to  exercise  a  direct  inhibitory  effeqt  upon  the  activity 
of  the  tuberculous  process  in  the  lung".  We  have  ourselves 
never  seen  such  inhalation  produce  in  febrile  cases  any 
marked  alteration  in  the  temperature  chart,  and  believe  that 
the  good  effect  is  restricted  to  a  lessening  of  the  bronchial 
catarrh  and  its  attendant  cough. 

Another  valuable  prescription  from  the  Brompton  Hospital 
Pharmacopoeia  is  the  following :  Menthol  3ii.,  Creosote  3i.ss., 
Spiritfis  Camphorse  oi.ss.,  Spiritum  Rectificatum  ad  gi.  In 
some  cases,  especially  when  the  cough  is  frequent  and  expec- 
toration abundant,  a  large  bib  may  usefully  be  employed, 
sprinkled  with  a  weak  formalin  solution  (2^  to  5  per  cent.). 
This  has  the  double  advantage  of  serving  as  an  antiseptic 
inhalation,  weak  but  constant,  and  of  catching  the  spray  of 
the  cough  in  bedridden  patients. 

A  good  sedative  inhalation,  especially  when  the  larynx  is 
involved,  is  produced  by  placing  a  few  crystals  of  menthol  in 
a  dry  tumbler  and  immersing  it  in  hot  water.  In  cases  also 
where  there  is  much  tracheal  irritation,  causing  incessant 
cough,  ten  or  twenty  drops  of  chloroform,  inhaled  from  a 
smelling"-bottle  or  a  handkerchief  stretched  across  the  open 


682  DISEASES   OF  THE  LUNGS   AND   PLEURA 

mouth,  will  give  great  relief;  but  this  remedy  must  be  used 
with  caution  and  watchfulness.  *  It  must  be  remembered  that 
cough  is  the  only  means  by  which  the  phthisical  lesions  can 
be  drained  of  their  deleterious  products,  and  cough  cannot 
therefore  be  smothered  by  sedative  remedies  without  damage 
to  the  patient. 

There  are  certain  times  and  kinds  of  coughing  which  call 
for  special  treatment,  particularly  (a)  the  irritable  and  ineffec- 
tual cough,  (b)  the  night  cough,  (c)  the  early-morning  cough. 

(a)  The  irritable  and  ineffectual  cough,  in  which  only  a 
very  scanty  expectoration  follows  after  prolonged  and  ex- 
hausting efforts,  can  to  some  extent  be  controlled  by  the 
patient  himself,  and  he  should  be  encouraged  to  repress  it  as 
far  as  possible.  In  other  cases  treatment  is  indicated,  and  the 
symptom  may  be  best  modified  by  the  use  of  one  or  other 
of  the  sedative  respirators  above  mentioned.  A  small  dose 
of  opiate,  such  as  five  minims  of  nepenthe,  or  heroin  gr.  yV, 
may  for  a  time  be  added  to  the  day  mixture.  These  irritable 
coughs  generally  mean  that  caseating  and  softening  lesions 
have  not  yet  established  communication  with  the  bronchi,  and 
with  this  occurrence  the  cough  becomes  looser  and  more  easy. 

(b)  Night  cough  requires  sedative  treatment  by  opium, 
chloral,  heroin  or  codein.  A  combination  of  small  doses  of 
these  drugs,  made  up  to  a  tablespoonful  with  mucilage  and 
chloroform  water  (see  p.  672),  is  often  valuable,  and  may  be 
repeated  in  half-doses  once  or  twice  in  the  night  if  necessary. 
The  Pilula  Ipecacuanhse  cum  Scilla  of  the  Pharmacopoeia  is 
also  useful.  When  the  cough  is  described  as  very  "tight,"  an 
opiate  may  be  taken  in  an  alkaline  effervescing  draught  at 
bedtime. 

(c)  The  morning  cough,  to  which  we  have  already  alluded 
(p.  673),  requires  quite  a  different  treatment;  it  should  never 
be  checked  by  sedatives.  Its  severity  and  the  amount  of 
expectoration  are  generally  in  inverse  proportion  to  the 
quietude  of  the  night.  Expectoration  and  clearance  of  cavities 
should  be  encouraged  by  hot  stimulating  drinks,  such  as  a 
cup  of  hot  coffee  or  milk  (with  perhaps  a  liqueur  glass  of 
cog'nac  or  rum),  or  a  dose  of  ether  and  ammonia.  Some- 
times a  hot,  stimulating  poultice  over  the  sternum  is  useful; 
for  example,  a  linseed  poultice,  with  powdered  camphor,  in 
proportion  of  one  ounce  camphor  to  one  pound  Hnseed.     It 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  683 

is  an  advantage  if  the  lungs  can  thus  be  cleared  before  break- 
fast, as  there  is  then  less  tendency  for  the  cough  to  induce 
vomiting.  We  may  here  allude  to  the  highly  irritating  effects 
upon  the  stomach  of  the  products  of  caseous  softening  and 
cavity  secretion,  when  swallowed.  Some  patients,  delicate- 
minded  females  and  sensitive  men,  feel  a  reluctance  or  a  timid- 
ness  in  expelHng  the  products  of  their  disease;  children  espe- 
cially fail  to  do  so.  This  inability  or  unwillingness  to  eject 
the  sputa  is  a  fruitful  source  of  stomach  and  bowel  troubles, 
and  of  local  tuberculosis ;  a  simple  warning  will  often  prevent 
the  necessity  for  special  medication.  A  pleasant  antiseptic 
mouth-wash  should  be  used  after  the  morning  expectoration. 

Night-sweating. — This  is  a  symptom  which  usually  calls 
for  treatment  from  time  to  time  during  the  eliminative  period 
of  phthisis,  but  is  of  much  less  frequent  occurrence  since  the 
introduction  of  the  open-air  lines  of  treatment.  It  arises  from 
two  principal  causes — viz.,  fever  and  nervous  exhaustion,  these 
causes  being  commonly  combined,  but  the  one  or  the  other 
predominating  in  different  cases. 

There  are  innumerable  empiric  remedies  for  night-sweats, 
all  of  them  successful  in  certain  cases.  They  should  not,  how- 
ever, be  used  until  such  rational  measures,  as  are  indicated  by 
the  causative  conditions  above  alluded  to,  have  been  adopted. 

The  patient  must  be  steadily  supported  by  nourishment  dur- 
ing the  day,  and  some  readily  digestible  food,  such  as  strong- 
beef  essence,  given  the  last  thing  at  night.  Fever  must  be 
moderated  by  tepid  acid  sponging  at  bedtime  (a  wineglassful 
of  aromatic  vinegar  with  eau-de-Cologne  to  a  tumbler  of 
water),  and  a  third  dose  of  the  quinine,  or  acid  tonic  in  use 
may  be  given  a  little  before  bedtime.  In  many  cases  we  have 
found  a  mixture  containing  two  grains  of  quinine  sulphate 
and  twenty  minims  of  dilute  hydrobromic  acid  of  value.  If 
these  means  prove  insufficient,  then  aid  may  be  sought  from 
specific  remedies.  Extract  of  belladonna  gr.  |,  or  atropine 
gr.  TOcy,  may  be  given  in  the  form  of  pill  at  night  either  alone 
or  in  combination  with  quinine.  If  the  cough  is  troublesome, 
hyoscyamine  gr.  i^  may  be  preferred.  When  the  hectic  has 
lasted  some  time,  and  has  resulted  in  much  nervous  ex- 
haustion, strychnia  is  useful  in  full  doses  at  bedtime,  but  this 
remedy   is   sometimes    unfortunate    in    causing   wakefulness. 


684  DISEASES   OF   THE  LUNGS   AND   PLEURA 

Four-grain  doses  of  oxide  of  zinc,  or  two  grains  of  valerianate 
of  zinc  will  sometimes  answer  alone  or  in  combination  with 
belladonna. 

In  cases  in  which  night-sweating  is  observed  to  be  preceded 
by  shallow  breathing  and  slight  livid  pallor,  strychnine  is 
especially  indicated.  A  current  of  oxygen  occasionally 
broug'ht  near  the  patient  during  sleep  may  also  prove  of 
service. 

Agaricin  gr.  tV,  and  camphoric  acid  gr.  xv.,  are  other 
remedies  of  occasional  value,  their  good  effect  being  appar- 
ently due  to  their  depressing  action  upon  the  nerve-endings 
to  the  sweat-glands." 

It  is  of  the  utmost  importance  to  have  some  easily  assimi- 
lable food,  such  as  good  cold  beef-tea  or  beef-essence,  ready 
to  hand,  should  the  patient  wake  up,  and  especially  with  night 
perspiration,  for  the  sweats  are  profoundly  depressing  from 
the  large  quantity  of  saline  material  discharged,  and  the 
nervous  exhaustion  thus  induced  tends  to  perpetuate  their 
nig'htly  recurrence.  The  immediate  supply  of  a  stimulating 
salt-containing  food  tends  to  remedy  the  loss  and  to  prevent 
its  recurrence.  Patients  liable  to  night-sweating  should  wear 
a  thin  flannel  loosely-fitting  over-gown,  and  a  fresh  night- 
dress should  always  be  ready  aired  for  changing. 

General  Summary. — Throughout  the  variable  but  often  pro- 
longed period  of  suppurative  fever  through  which  the  patient 
has  to  pass  during  the  softening  and  elimination  of  the 
caseous  products  in  the  more  active  forms  and  periods  of 
phthisis,  the  lines  of  treatment  to  be  followed  may  thus  be 
summarised. 

(a)  The  patient  must  be  kept  absolutely  at  rest  in  bed,  and 
open-air  lines  of  treatment  strictly  enforced.  If  the  condi- 
tions are  satisfactoiy,  this  can  be  well  carried  out  in  the 
patient's  own  home,  a  shelter  being  erected  in  the  garden,  in 
which  he  may  lie  out,  and,  even  under  favourable  conditions, 
spend  the  night.  Treatment  in  a  sanatorium  in  this  stage  of 
the  disease  is  not  essential,  and,  indeed,  cases  of  this  kind  are 
not  altog'ether  welcome  in  such  institutions,  requiring',  as  they 
do,  additional  attention  and  nursing.  In  cases  where  the 
home  is  situated  in  the  midst  of  damp  and  unhealthy  sur- 
roundings, a  rem.oval  to  a  high  and  dry  locality,  or  to  the 
seaside,  with  sunny  exposure,  cannot  fail,  ceteris  paribus,  to 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  685 

be  beneficial.  No  climatic  change  of  any  radical  kind  is  indi- 
cated for  this  period  of  the  disease.  For  the  poorer  classes 
our  larg"e  special  hospitals  are  admirably  adapted.  Unfortu- 
nately febrile  cases  of  the  type  considered  in  this  chapter  are 
not  always  welcome  even  here,  but  it  is  clearly  the  duty  of 
every  such  hospital  to  provide  for  a  certain  percentage  of 
such  patients.  In  every  county  there  should  also  be  told  off 
a  certain  portion  of  the  infirmary,  so  reconstructed  as  to 
afford  especial  comfort  and  good  hygienic  conditions,  and 
thus  adapted  for  active  as  well  as  advanced  cases  of  phthisis. 

(b)  The  patient  must  be  steadily  supported  by  an  abundant 
and  well-assorted  dietary,  rich  in  fats  and  nitrogenous  ele- 
ments. If  milk  can  be  borne,  one  or  two  pints  should  be  taken 
daily,  as  the  patient  is  usually  somewhat  wasted.  In  some 
cases  a  light  wine  or  beer,  or  other  form  of  alcohol,  is  of 
value. 

(c)  Particular  symptoms — pyrexia,  dyspepsia,  sweatings, 
cough,  and  expectoration — will  suggest  the  hne  of  medicinal 
treatment,  which  must  be  determined  upon  after  careful  con- 
sideration of  the  whole  case,  and  not  lightly  changed.  A 
written  sketch  of  the  dietary  and  times  of  taking  medicine 
will  be  a  useful  guide  to  friends  and  nurses,  and  a  wholesome 
check  against  mixtures  "  every  four  hours  "  and  cough  Hnctus 
"  occasionally,"  besides  pills  for  night-sweats,  and  local  appli- 
cations, a  wholesale  medication,  which  if  persisted  in  cannot 
fail  to  be  disastrous. 


REFERENCES. 

'    The    First    Medical    Re-port    of    the    Hospital    for    Consumption    and 
Diseases  of  the  Chest,  p.  38.     London,  1849. 

^  Pulmonary   Consumption,   by   C.   J.    B.    Williams,   M.D.,    and   Charles 
Theodore  Williams,  M.D.,  second  edition,  p.  336.     London,  1887. 

(i)  "  The  Digestibility  of  Fats  and  Oils,  etc.,"  by  John  W.  WeUs, 
M.B.,  British  Medical  Journal,  1902,  vol.  ii.  p.  1222. 

(2)  The  Influence  of  Cod-Liver  Oil  on  Tuberculosis,  by  J.  W.  Wells, 
M.B.     Manchester,   1907. 

[a]  "  The  Influence  of  the  Unsaturated  Fatty  Acids  in  Tuberculosis," 
by  Owen  T.  WilHams,  M.D.,  and  Charles  E.  P.  Forsyth,  M.B., 
British  Medical  Journal,  iQOQj  vol.  ii.,  p.  1120. 

[b)  "  Cod-Liver  Oil  and  its  Action  in  Phthisis,"  by  Owen  T.  Williams, 
M.D.,  M.R.C.P.,   ibid.,  1912,  vol.  ii.,  p.  700. 


3 


686  DISEASES   OF  THE  LUNGS   AND   PLEURA 

^  "A  Note  on  Sodium  Morrhuate  in  Tuberculosis,"  by  Sir  Leonard 
Rogers,  Kt.,  CLE.,  M.D.,  F.R.C.P.,  F.R.S.,  British  Medical  Journal, 
1919,  vol.  i.,  p.  147. 

^  "  Ueber  schadliche  und  niitzliche  Wirkungen  der  Fieber-temperatur 
bei  Infektionskrankheiten,"  von  Fr.  Roily,  MUnchener  Medizinische 
W ochenschrijt,  1909,  April  13. 

'  "  On  the  Use  of  Neo-salvarsan  in  Active  Pulmonary  Tuberculosis," 
by  P.  Horton-Smith  Hartley,  C.V.O.,  M.D.,  F.R.C.P.,  The  Lancet,  1914, 
vol.  i.,  p.  1602. 

*  [a)  "  Observations  on  the  Action  of  Iodine,  and  also  on  Nev^r  Methods 
of  Using  It,"  by  David  Curie,  M.D.,  The  Practitioner,  vol.  Ixxxix., 
1912,  p.  846. 
(b)  "  The  Treatment  of  Phthisis  by  Intensive  Nascent  Iodine  Adminis- 
tration," by  Edward  G.  Reeve,  M.R.C.S.,  L.R.C.P.,  The  Practioner, 
vol.  xcL,  1913,  p.  391. 

°  See  "  On  the  Use  of  Cryogenin  in  Phthisis,''  by  James  Calvert,  M.D., 
St.  Bartholomew's  Hosfital  Re-ports,  1907,  vol.  xliii.,  p.  51. 

"  See  "  Antiseptic  Inhalation  in  Pulmonary  Affections,"  by  J.  Sinclair 
Coghill,  M.D.,  British  Medical  Journal,  1881,  vol.  i.,  p.  841. 

^^  See  "  Use  and  Abuse  of  Drugs  in  Tuberculosis,"  by  Professor  W.  E. 
Dixon,  M.A.,  M.D.,  F.R.S.,  The  Practitioner,  January- June,  1913,  p.  no. 


CHAPTER   XLVIII 

TREATMENT    OF    PULMONARY   TUBERCULOSIS— {Con(inued) 

The  more  Quiescent  Period — Contracting,  Secreting,  and 
Ulcerous  Cavities — Fibroid  Stage. 

In  dealing  with  the  pathology  of  pulmonary  tuberculosis,  we 
pointed  out  how  the  disease,  in  most  of  its  varied  mani- 
festations, shows  a  disposition  to  periods  of  quiescence;  and  it 
is  during-  these  periods,  sometimes  occurring  in  the  earlier 
stages,  sometimes  after  a  prolonged  hectic  stage  resulting-  in 
completed  excavation  of  a  large  portion  of  a  lung,  that  an 
appropriate  and  definite  treatment  may  succeed  in  producing 
permanent  arrest.  It  is  at  these  periods  also  that  most  may 
be  expected  from  climatic  change  (see  p.  636). 

In  these  stages  the  preparations  of  creosote  and  its  con- 
geners, especially  guaiacol,  are  of  distinct  value.  The  use  of 
these  remedies,  long  since  suggested  and  abandoned,  was 
resuscitated  when  the  specific  nature  of  tubercle  was  finally 
demonstrated.  Bouchard  and  Gimbert  in  France,^  and  Som- 
merbrodt^  in  Germany,  appear  to  have  been  the  first  to  re- 
introduce them,  and  they  were  long  in  use  by  the  French 
physicians  before  they  became  seriously  employed  in  this 
country.  Their  value  in  many  cases  of  phthisis,  and  especially 
at  the  stages  indicated,  cannot  be  doubted,  although  the  exact 
mode  by  which  their  effect  is  produced  remains  obscure. 

Creosote  and  guaiacol  may  be  prescribed  in  the  form  of 
capsules,  containing-  from  one  to  three  or  more  minims.  A 
two-minim  capsule  should  be  taken,  in  the  first  instance,  im- 
mediately after  food  three  times  a  day,  and  the  dose  gradually 
increased.  Some  patients  can  take  the  drugs  better  when  held 
in  solution  by  rectified  spirit,  and  flavoured  by  a  liqueur  or 
bitter.     Cod-liver  oil  is  another  good  vehicle;  doses  up  to  10, 

or  even  20  minims  of  the  creosote  being  dissolved  in  two 

687 


688  DISEASES    OF   THE  LUNGS    AND   PLEURA 

drachms  of  the  oil,  to  be  taken  twice  a  day  after  food.  Most 
patients  are  able  in  this  way  to  tolerate  the  required  dose  of 
the  drug  without  derangement  of  the  stomach.  It  is  not  as  a 
rule  necessary  to  prescribe  very  large  doses  of  the  drug',  but 
moderate  doses  should  be  persisted  with  for  a  long  time. 
Other  formulas  which  we  have  found  of  practical  value  have 
been  the  following : 

(a)  J^  Guaiacol  carbonatis,  Guaiacol  benzoatis  vel  Styracol        5i-ss. 

Calcii  hypophosphitis  ...  ...  ...  ...         5ss. 

Pulvis  Tragacanthte  Co.     ...  ...  ...  ...         5i- 

Misce  bene,  adde  guttatim  : 

Syr.  Pruni  Virginianae  vel  Elixir  Aurantii  (U.S.P.)...         §ss. 
Syr.     Calcii    Lacto-phosphatis    vel     Syr.     Hypophos- 
phitum  Co.         ...  ...  ...  ...  ...         oi- 

Aquam  Chloroformi  ...  ...  ...  ...  ad  gvi. 

One  tablespoonful  in  water  or  liquid  malt  three  times  a  day  soon  after 
food. 

(b)  1^  Creosoti  Carbonatis  ...  ...  ...  ...         3iv. 

Tinct.  Gentianse  Co.  ...  ...  ...  ...         oi"^- 

Syr.  Pruni  Virginians       ...  ...  .'..  ...  ad  §iii. 

One  teaspoonful  in  a  wineglass  of  water  or  malt  extract  after  food 
three  times  a  day.  Increase  the  dose  by  five  drops  each  second 
day  up  to  two  teaspoonfuls  by  measure. 

It  is  sometimes  desirable,  in  patients  with  delicate  digestion, 
to  secure  that  the  creosote  preparation  shall  pass  throug'h  the 
stomach  undissolved,  to  be  absorbed  from  the  intestinal  tract. 
This  may  be  effected  by  the  use  of  "  proposote,"  a  combination 
of  creosote  and  phenyl-propionic  acid  introduced  by  Messrs. 
Parke  Davis  and  Co.  Proposote  is  insoluble  in  water  and 
acids,  but  is  decomposed  by  alkaline  fluids  into  creosote  and 
phenyl-propionic  acid.  It  is  best  prescribed  in  capsules, 
10  minims  corresponding  to  5  minims  of  creosote. 

The  idea  of  destroying  the  tubercle  bacillus  by  any  inter- 
nally administered  antiseptic  has  been  abandoned,  and 
the  effects  of  creosote  treatment,  when  successful,  are  recog- 
nised as  chiefly  to  diminish  expectoration,  to  lessen  waste  of 
tissues,  and  to  render  them  less  susceptible  to  tuberculous 
acti\nty. 

Quiescent,  Secreting,  and  Ulcerous  CaYities. — We  may  now 
pass  to  a  consideration  of  the  cavities,  which  form  so  con- 
spicuous a  feature  in  many  cases  of  phthisis.  In  certain 
patients,  after  the  pulmonary  disease  has  ceased  to  extend, 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  689 

the  cavities,  varying  in  size  and  number,  become  quies- 
cent, and  slowly  contract,  yielding  less  and  less  secretion. 
In  these  cases  of  drying  and  contracting  cavity  the  cough 
becomes  irritable,  and  the  patient  frequently  complains  of  its 
"tightness,"  having  been  accustomed  to  easy  expectoration 
whilst  the  secretion  was  abundant.  He  should  be  encouraged 
by  explaining  to  him  the  favourable  nature  of  the  cause  of 
his  difificulty,  and  directed  to  check,  so  far  as  possible,  by  an 
effort  of  will,  the  tendency  to  violent  cough.  Sedative  cough 
mixtures,  or  the  addition  of  iV  gr.  of  heroin  to  the  day  mix- 
ture, etc.,  injurious  whilst  the  expectoration  was  abundant, 
now,  judiciously  timed,  become  of  much  value.  More  or  less 
morning  expectoration  persists  for  a  considerable  time  after 
the  cough  has  ceased  during  the  day,  and  should  not  be 
checked  by  sedatives.  It  must  not  be  forg'otten,  too,  that  the 
morning  expectoration  may  for  months,  and  even  for  years, 
contain  a  certain  number  of  more  or  less  ill-conditioned 
tubercle  bacilli  which  do  not  necessarily  affect  the  patient's 
general  well-being,  since  they  are  shut  off  by  the  dense  fibroid 
surroundings  of  the  cavity.  The  further  hygienic,  climatic, 
and  medicinal  treatment  of  cases  of  this  kind  must  be  con- 
ducted on  general  principles. 

It  is  of  great  importance  to  keep  such  patients  in  a  pure 
atmosphere,  since  they  are  most  sensitive  to  all  septic  condi- 
tions. Under  unfavourable  hygienic  circumstances  the  cavi- 
ties become  secreting,  and  other  surrounding  centres  of 
disease  take  on  fresh  activity. 

Moorland,  sea,  and  mountain  air  are  all  suitable  for  these 
cases,  and  one  or  other  should  be  advised  in  accordance  with 
the  special  indications  (see  chapters  on  Chmatic  Change).  As 
the  patient's  strength  improves,  the  development  of  the  sound 
portions  of  the  lungs  may  be  encourag-ed  by  carefully  regu- 
lated exercise  on  rising  ground.  It  is  in  this  latter  phase, 
provided  the  extent  of  lesion  be  not  too  great,  that  moun- 
tain resorts  prove  so  valuable. 

Secreting  Cavities  may,  as  already  pointed  out,  persist  from 
the  acute  stage,  or  be  developed  by  renewed  activity  of  the 
lining  of  cavities  which  had  become  quiescent. 

The  objects  which  we  have  in  view  in  the  treatment  of  such 
cases,  are — (i)  to  lessen  secretion;  (2)  to  promote  its  evacua- 
tion ;  and  (3)  to  disinfect  the  cavities. 

44 


690  DISEASES   OF  THE  LUNGS   AND   PLEURA 

Counter-irritation  is  useful  over  the  cavities  in  the  form 
of  strong  iodine  applications,  or  flying  bhsters,  or  perhaps  a 
blister  kept  open  for  a  time  by  savin  ointment.  A  course  of 
mineral  acids,  in  combination  with  bark  or  astringent  iron 
tonics,  with  cod-hver  oil,  is  from  time  to  time  needed. 

It  is  in  these  cases  in  which,  with  Httle  or  no  pyrexia,  there  is 
yet  considerable  secretion  from  cavities,  that  the  preparations 
of  tar,  creosote,  or  eucalyptus  may  often  be  given  in  moderate 
doses  with  great  advantage.  Tar  may  be  best  prescribed  in  a 
morning  and  evening  dose  of  the  eau  de  goudron  of  Guyot, 
from  3ss.  to  3i.ss.  in  a  wineglass  of  plain  or  some  mineral 
water  (Ems,  Bourboule,  Vichy),  to  which  a  little  warm  milk, 
and,  if  necessary,  cognac  may  be  added;  a  single,  or  at  most 
two,  doses  of  tonic  being  given  during  the  day.  The  tonic 
may  from  time  to  time  be  varied  or  omitted,  but  the  tar  pre- 
paration should  be  persisted  in  for  weeks  or  months.  Bell's 
Liquor  Picis  Aromaticus,  in  doses  of  twenty  to  forty  minims 
(2  to  5  grains  of  tar),  is  also  a  useful  and  not  unpleasant 
preparation  ;  or  the  tar^may  be  prescribed  simply  as  a  pill. 

In  cases,  especially,  of  intercurrent  catarrh,  causing  an 
increased  secretion  from  quiescent  cavities,  five  or  ten  drops 
of  a  mixture  of  equal  parts  of  oil  of  eucalyptus  and 
pure  terebene,  taken  on  sugar  three  times  a  day  between 
meals,  may  be  prescribed  with  advantage.  When  the  secre- 
tion is  very  abundant  and  the  condition  of  the  patient  de- 
pressed, we  have  found  oil  of  eucalyptus,  held  in  solution  with 
a  drachm  of  rectified  spirit,  with  the  addition  of  glycerine  and 
a  little  dilute  phosphoric  acid  and  quinine,  a  useful  com- 
bination. 

Subcutaneous,  or  rather  intramuscular  injections  of  creo- 
sote or  guaiacol,  dissolved  in  sterilized  oil,  have  been  em- 
ployed in  this,  and  also  in  the  more  active  stage  of  phthisis. 
We  have  had  opportunities  of  noticing  the  results  of  this 
method  of  treatment,  but  have  been  by  no  means  convinced 
of  its  superiority;  the  imagination  of  the  patient  cannot  fail 
for  a  time  to  be  impressed,  but  at  the  cost  of  considerable 
discomfort,  and  in  some  instances  of  no  little  positive  suffer- 
ing", local  necrosis  sometimes  occurring  at  the  seat  of 
injection. 

If  the  opsonic  index  with  regard  to  any  particular  organism 
in  the  sputum  (whether  streptococcus  or  other)  is  found  to  be 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  69I 

depressed,  it  may  be  raised  by  the  employment  of  a  suitable 
vaccine,  under  which  treatment  the  amount  of  secretion  will 
sometimes  diminish. 

Sedative  cough  mixtures  are  directly  contra-indicated  except 
at  bedtime,  and  then  solely  for  the  purpose  of  procuring  rest. 

Seaside  resorts,  the  more  bracing  of  the  Riviera  stations, 
are  the  climates  most  suitable  for  these  cases  in  the  first  place, 
but  many  will  after  a  time  continue  to  make  better  progress 
in  the  dry  Alpine  or  South  African  highlands,  provided  the 
other  indications  for  such  climates  are  fulfilled  (see  Chap- 
ter XLV.). 

Ulcerous  Cavities. — Cases  of  ulcerous  or  active  cavities  are 
always  to  be  regarded  as  probably  due  to  insanitary  surround- 
ings, and  such  evil  conditions  must  be  first  looked  to  and 
remedied.  These  cases  are  of  an  erysipelatous  type,  and 
under  the  more  recent  methods  of  hygienic  treatment  are  now 
rarely  met  with;  they  are  best  treated  by  quinine  in  full  doses, 
or  perhaps  tincture  of  iron,  and  locally  by  sedative  inhalations 
of  carbolic  acid,  conium,  and  chloroform,  with  hot-water 
vapour.* 

After  the  more  active  general  symptoms  have  lessened,  if 
the  blood-stained  and  copious  expectoration  lead  us  still  to 
infer  that  the  walls  of  the  cavity  are  hypersemic,  if  not  ulcer- 
ated, the  best  treatment  will  be  found  to  be  free  counter-irri- 
tation. A  blister  should  be  applied  over  the  site  of  the  cavity, 
and  should  be  kept  freely  discharging  for  a  week  or  ten  days 
by  means  of  savin  ointment  dressing.  We  have  seen  the 
active  local  symptoms  completely  subside  under  this  treat- 
ment, and  the  expectoration,  from  being  abundant  and  san- 
guineous, become  scanty  and  viscid,  apparently  consisting  of 
bronchial  mucus  only. 

With  regard  to  the  possibility  of  surgical  intervention  in  the 
treatment  of  phthisical  cavities,  we  must  refer  the  reader  to 
a  later  chapter  (p.  728). 

Chronic  and  Fibroid  Stage.— The  management  of  the 
chronic  and  fibroid  stages  of  pulmonary  tuberculosis  consists 
chiefly  in  the  prevention  of  fresh  catarrhs,  which  may  lead  in 
turn  to  the  further  spread  of  disease.  To  this  end  all  insani- 
tary conditions  must  be  avoided,  clothing  should  be  suitable, 

*  Chloroformi  mx.,  Succi  Conii  3i.,  Glycerinum  Acidi  Carbolici  ad  5ii., 
Aq.  Bullientis  gviii. — Bromfton  Hosfital  Pharmacofxia. 


692  DISEASES   OF  THE  LUNGS   AND   PLEURA 

and  the  diet  nutritious  but  not  stimulating.  When  prac- 
ticable, also  a  more  genial  climate  should  be  selected,  thus 
insuring  protection  from  irritating  fogs  and  cold  damp 
winds.  Iodine  applications,  soothing  or  antiseptic  inhala- 
tions (carbolic  acid  being  particularly  useful  when  there  is 
any  foetor  of  expectoration),  seem  the  best  local  remedies. 
The  general  condition,  including  that  of  digestion,  and  the 
nature  of  the  cough  and  amount  of  expectoration,  supply  us 
with  indications  for  the  administration  of  appropriate  drugs — 
iron,  cod-liver  oil,  strychnia,  alkalies,  tonics,  creosote,  etc. — or 
warrant  the  withdrawal  of  all  medicines. 

There  is  only  one  special  remark  concerning  the  treatment 
of  these  chronic  indurative  cases  of  phthisis,  during  the  often 
extended  period  of  quiescence,  which  seems  called  for,  and 
it  is  this  :  that,  having  lived  to  acquire  their  immunity,  such 
cases  do  not  require  the  persistent  administration  of  tonic 
medicines  and  cod-liver  oil,  although  needing  careful  sur- 
veillance, and  for  several  years,  where  practicable,  carefully 
selected  climates  to  suit  the  different  seasons  of  the  year. 
They  improve  immensely  under  such  remedies  up  to  a  certain 
point,  which  may  be  readily  recognised  by  the  medical  atten- 
dant, and  cannot  be  better  described  than  by  saying  that  it 
amounts  to  the  most  perfect  health  attainable  by  a  patient 
who  has  had  a  certain  area  of  respiratory  surface  cut  off.  If 
beyond  this  point  we  persevere  with  iron  and  oil,  and  too 
nourishing  or  stimulating  a  diet,  we  may  still  further  increase 
weight  and  heighten  colour,  but  the  pulse  quickens,  the 
patient  gets  more  short  of  breath,  he  becomes,  in  a  word, 
plethoric,  and  liable  to  pulmonary  congestion  and  haemoptysis, 
or  to  dyspepsia  and  diarrhoea.  A  rapid  neutralisation  of  all 
the  good  results  obtained,  with  great  danger  of  fresh,  and 
perhaps  fatal  renewal  of  the  old  disease,  is  thus  the  conse- 
quence of  too  great  anxiety  to  arrive  again  at  a  degree  of 
health  and  bodily  vigour  which  is  impossible  wth  a  per- 
manently damaged  lung. 

The  treatment  of  pulmonary  tuberculosis  occurring  in  the 
course  of  diabetes  calls  for  no  detailed  comments.  In  such 
cases  a  considerable  abatement  in  the  regime  for  diabetes  is 
usually  necessary,  and  codeia,  quinine,  and  cod-liver  oil  are 
indicated. 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  693 


REFERENCES. 

'  "  Note  sur  I'Emploi  de  la  Creosote  vraie  dans  le  Traitement  de  la 
Phthisie  Pulmonaire,"  par  MM.  Ch.  Bouchard  (de  Bicetre)  et  Gimbert  (de 
Cannes),  Gazette  Hebdomadaire  de  Medecine  et  de  Ckirurgie,  1877,  No.  31, 
p.  486. 

^  "  Ueber  die  Behandlung  der  Lungentuberkulose  mit  Kreosot,"  von 
Professor  Dr.  Julius  Sommerbrodt  (in  Breslau),  Berliner  Klinische  Wochen 
schrift,  1887,  No.   15,  p.  258. 


CHAPTER  XLIX 

TREATMENT  OF  THE  COMPLICATIONS  OF  PULMONARY 

TUBERCULOSIS 


Ulceration  of  the  Bowel — Laryngeal  Tuberculosis — 
HsBmopty  sis — Vomiting — Intercurrent    Pleurisy — Meningitis . 

Ulceration  of  the  Bowel. — In  the  treatment  of  ulceration  of 
the  bowel  in  phthisis  it  may  be  usefully  remembered  that  the 
mere  presence  of  such  ulcers  does  not  necessarily  cause  diar- 
rhoea, this  symptom,  when  present,  being  due  to  increased 
peristalsis  set  up  by  an  active  condition  of  the  ulcer,  or  to 
attendant  catarrhal  inflammation  of  the  adjacent  mucous 
membrane.  We  have  thus  two  conditions  to  bear  in  mind  in 
the  treatment  of  tuberculous  ulceration  of  the  bowels — viz. : 
(i)  acute  ulceration,  the  first  stage  of  the  disease,  in  which 
the  ulcers  are  in  process  of  formation  or  activity;  (2)  chronic 
ulceration,  associated  with  diarrhoea  alternating'  with  con- 
stipation, or  with  attacks  of  intercurrent  looseness  of  bowel 
arising  from  errors  of  diet. 

Acute  Ulceration.— In  this  condition,  the  symptoms  of 
which  have  been  already  described  (see  p.  542),  the  diet  must 
be  carefully  regulated,  so  as  to  give  as  Httle  residue  as  pos- 
sible. The  patient  must  be  kept  warm  in  bed,  and  food 
restricted  to  milk  and  a  httle  good  beef-tea  or  meat  essence. 
Four  or  five  ounces  of  milk,  citrated  if  necessary,  should  be 
allowed  every  two  hours,  and  at  certain  intervals  the  milk 
may  be  replaced  by  beef-tea,  half  a  pint  of  which,  equivalent 
to  half  a  pound  of  meat  (see  p.  330),  may  be  allowed  in  the 
twenty-four  hours.  The  milk  can  be  given  warm  or  cold, 
in  accordance  with  the  desire  of  the  patient;  sometimes  a 
little  crushed  ice  may  be  added,  or  it  may  be  boiled  with  rice 
and  strained,  when  six  ounces  should  be  allowed  instead  of 
four.     If  further  nutriment  is  required,  the  milk  should  be 

694 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  695 

thickened  three  or  four  times  a  day  with  a  Httle  plasmon  or 
sanatogen.  In  other  cases  Beng'er's,  or  other  pancreatised  or 
malted  farinaceous  food,  may  be  prepared  with  the  milk  twice 
or  thrice  daily.  Sometimes  koumiss  in  the  third  degree  of 
fermentation  (see  p.  603)  may  be  substituted  for  milk.  The 
beef-tea  can  be  varied  with  veal-tea,  chicken  or  mutton 
broth,  and  the  latter  may  occasionally  with  advantage  be 
added  to  the  milk.  After  a  few  days,  rusks  and  a  little  tea 
may  be  allowed,  and  the  diet  slowly  improved  through  such 
grades  as  custards,  ground-rice  puddings,  invalid  turtle, 
scalded  bread-and-milk,  pounded  chicken,  and  the  like.  As 
the  diet  is  improved,  the  intervals  between  the  times  of  taking 
food  should  be  increased  to  three  or  four  hours. 

In  some  cases  a  small  quantity  of  stimulant  in  the  form  of 
brandy,  added  to  each  second  quantity  of  the  milk,  is  of  ser- 
vice, or  a  little  old  port  wine  may  be  allowed. 

During  the  acute  period  now  under  consideration,  and 
whilst  any  tenderness  remains,  the  patient  will  be  best  in 
bed,  and  a  pine  wool  pad,  or  calorigen  or  thermogen  wool, 
should  cover  the  abdomen.  When  there  is  marked  tender- 
ness over  the  region  of  the  caecum,  a  small  blister  may  with 
advantage  be  applied  in  this  situation  under  a  poultice. 

In  medicinal  treatment  it  is  of  importance,  first  of  all,  to 
clear  away  any  irritating-  matter  from  the  bowel,  and  the 
administration  of  from  one  to  two  drachms  of  castor  oil,  well 
shaken  up  with  two  ounces  of  hot  milk,  and  a  dessert-spoon- 
ful of  cognac  added,  will  prove  of  service.  It  is  often  a  good 
plan  to  give  a  small  dose,  half  to  one  grain,  of  calomel  two 
hours  previous  to  the  dose  of  oil.  After  the  lapse  of  a  few 
hours,  to  allow  the  effect  of  these  medicines  to  take  place, 
ten  or  fifteen  grain  doses  of  bismuth,  with  half  a  grain  of 
ipecacuanha,  and  ten  grains  of  sulphccarbolate  of  soda  in 
mucilage  and  chloroform  water,  is  a  good  routine  treatment. 
After  some  eight  or  twelve  doses,  a  httle  chalk  mixture 
should,  if  needed,  be  added  in  place  of  the  soda.  Sometimes 
cerium  will  answer  better  than  bismuth,  and  in  cases  of  pain- 
ful peristalsis  small  doses  of  opium  are  needed. 

When  there  is  much  tympanites  and  tenderness,  five  minims 
of  glycerine  of  carbolic  acid,  thirty  minims  of  the  solution  of 
perchloride  of  mercury,  and  five  minims  of  tincture  of 
opium,  with  compound  tincture  of  chloroform,  a  little  sul- 


696  DISEASES   OF   THE  LUNGS   AND   PLEURA 

phocarbolate  of  soda,  and  some  aromatic  water  every  four 
hours  for  a  day  or  two,  may  be  of  g'reat  service.  In  some  of 
these  cases  carbonate  of  guaiacol  will  be  found  useful, 
especially  after  the  more  acute  stage  has  passed. 

It  is  the  greatest  possible  mistake  to  treat  tuberculous  diar- 
rhoea with  astring'ents  and  opiates  as  a  matter  of  routine,  and 
without  very  carefully  looking"  to  the  diet.  This  treatment  is 
on  a  par  with  that  of  pulmonary  lesions  by  sedative  cough 
mixtures,  and  only  serves  to  mask  symptoms  whilst  the  tuber- 
culous lesions  are  spreading-  and  deepening. 

Chronic  Ulceration. — In  this  condition,  if  diarrhoea  super- 
vene upon  previous  constipation,  or  if  the  appearance  of  the 
motions  and  coated  tongue  lead  to  the  inference  that  scybal- 
ous or  irritating  materials  are  present  in  the  bowels,  a  dose 
of  castor  oil  or  compound  rhubarb  powder  should  first  be 
given,  the  dietary  carefully  gone  over  although  VN'ith  less 
strictness  than  in  the  acute  stage,  and  a  course  of  bismuth 
and  soda  or  chalk  prescribed. 

In  severe  cases  twenty  grains  of  bismuth  and  five  grains  of 
Dover's  powder  is  a  useful  combination,  or  ten  grains  each 
of  bismuth  and  compound  kino  powder  may  be  given  every 
three  or  four  hours.  In  a  much  more  limited  number  of  cases 
sulphuric  acid  and  opium  answer  better.  When  there  is  much 
tenderness  and  tympanites,  a  combination  of  carbolic  acid, 
mercury,  and  opium,  as  above  stated,  may  be  given  for  a  day 
or  two.  A  layer  of  pine  wool  quilted  on  flannel  should  be 
kept  firmly  applied  to  the  abdomen.  On  the  subsidence  of 
active  symptoms  a  little  calumba,  cascarilla,  or  quinine,  may 
be  given  twice  a  day  in  combination  with  fluid  bismuth;  or 
five-grain  doses  of  hypophosphite  of  lime  may  be  prescribed 
with  ten  minims  of  Liquor  Calcis  Saccharatus  in  calumba  or 
chiretta  infusion. 

Constipation  is  very  apt  to  follow  upon  diarrhoea  in  cases  of 
ulcerative  disease,  and  a  collection  of  solid  faeces  tends  to  re- 
awaken the  activity  of  the  ulcers.  The  smallest  available  dose 
of  laxative  should  therefore  be  prescribed  when  necessary, 
one  drachm  of  castor-oil  being  frequently  sufficient  when 
taken  well  emulsified  in  hot  milk.  The  diet  may  be  modified, 
and  a  little  fruit,  cider  or  light  beer  allowed  to  correct  the 
tendency  to  constipation,  care  being  taken  to  exclude  fibres, 
pips,  seeds  and  skins  of  fruits  and  vegetables.     In  cases  where 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  697 

the  third-stage  koumiss  has  been  taken  during  the  period  of 
diarrhoea,  a  return  to  medium  koumiss  may  be  suggested  as 
less  astringent. 

The  above  plan  of  treatment  will  be  found  most  generally- 
efficacious  in  cases  of  moderate  intensity  of  acute  and  of 
chronic  intestinal  ulceration,  and  during  periods  of  intercur- 
rent diarrhoea.  In  certain  cases  of  chronic  ulceration  with 
diarrhoea,  which  have  not  yielded  to  ordinary  methods  of 
treatment,  although  the  general  health  is  fairly  maintained, 
encouraging  results  have  been  obtained  with  heliotherapy  (see 
p.  641).  Cases  of  tuberculous  peritonitis  have  also  been  thus 
influenced  favourably.^'^ 

In  advanced  cases  the  diarrhoea  must,  as  far  as  possible,  be 
restrained  by  careful  diet,  but  our  therapeutical  resources  are 
often  taxed  to  the  utmost,  and  in  vain,  to  effect  more  than  a 
passing"  relief.  A  remedy  which  scarcely  ever  fails  to  give 
temporary  relief,  even  in  the  worst  cases,  is  the  starch  and 
opium  enema.  Some  acetate  of  lead  may  be  added  to  this 
enema,  or  the  lead  and  opium  suppository  may  be  employed 
with  advantage.  In  more  chronic  cases  and  those  of  great 
severity  we  still  have  a  large  armoury  of  more  decided  astrin- 
gents to  fall  back  upon,  amongst  which  acetate  of  lead  and 
sulphate  of  copper  (gr.  |),  with  opium,  hold  a  high  place. 
But  the  vegetable  astringents — kino,  catechu,  hsematoxylin, 
tannic  acid,  Indian  bael — may  be  each  in  turn  tried  in  com- 
bination with  opium,  with  decided,  but  often  only  temporary, 
benefit.  The  aromatic  chalk  and  opium  powder  of  the  Phar- 
macopoeia given  in  a  mixture  containing  tincture  of  catechu, 
is  a  favourite  remedy  in  these  cases.  Although  all  the  vege- 
table astringents  owe  their  efficacy  to  the  tannin  they  con- 
tain, yet  there  is  some  peculiarity  in  each,  and  when  one  has 
failed  another  will  often  succeed,  again  in  its  turn  to  lose  its 
virtues  in  the  particular  case.  Almost  all  these  cases  require 
opium  in  addition  to  the  astringent,  and  sometimes  opium 
alone  given  in  the  solid  form  is  the  best  remedy. 

Laryngeal  Tuberculosis.— The  treatment  of  tuberculosis  of 
larynx,  although  in  many  cases  unsatisfactory,  is  by  no  means 
so  gloomy  a  procedure  as  is  sometimes  imagined.  The  car- 
dinal principle  to  be  observed  is  to  give  rest  to  the  larynx  by 
checking  cough  and  enjoining  silence,  keeping  the  patient 
meanwhile  under  the  best  hygienic  conditions  possible.    Pro- 


698  DISEASES   OF  THE  LUNGS    AND   PLEURA 

vided  the  pulmonary  lesion  be  of  favourable  type  and 
amenable  to  treatment,  arrest  of  the  laryngeal  disease  not 
infrequently  occurs,  and  we  have  known  not  a  few  cases  of 
laryngeal  tuberculosis,  some  of  which  had  proceded  to  ulcera- 
tion, thus  undergo  arrest.  We  may  now  sketch  out  the 
treatment  in  greater  detail. 

If  the  laryngeal  trouble  shows  itself  when  the  pulmonary 
disease  is  in  a  comparatively  early  stage,  and  this  is  by  no 
means  uncommon,  treatment  in  a  sanatorium  should  be 
advised,  since  in  addition  to  such  local  measures  as  may  be 
required,  the  patient  will  have  also  the  benefit  of  the  general 
regime.  As  we  have  pointed  out  in  a  former  chapter,  the  sana- 
torium chosen  should  not  in  this  instance  be  at  too  high  an 
altitude,  or  in  too  cold  and  bracing  a  locality.  An  attempt 
must  also  be  made  to  insure  as  complete  rest  as  possible  to 
the  parts  by  urging  the  patient  to  refrain  from  all  unnecessary 
coughing.  An  irritable  cough  may  often  be  allayed  by 
the  use  of  an  antiseptic  inhalation,  containing-  menthol  and 
creosote,  or  other  remedies,  as  we  have  indicated  in  an  earlier 
chapter  (p.  681),  and  we  must  refer  the  reader  to  what  we  have 
there  said  in  regard  to  the  treatment  of  this  symptom. 
Measures  to  check  unnecessary  coughing  must  be  supple- 
mented by  enjoining  a  period  of  absolute  silence.  In  some 
cases  this  may  be  enforced  for  as  long  as  five  or  six  months, 
but  its  duration  must  depend  a  good  deal  upon  the  tempera- 
ment of  the  patient.  Occasionally  it  leads  to  considerable 
mental  depression,  and  must  then  be  shortened.  Such  patients 
can,  of  course,  converse  by  writing,  and  any  monotony  and 
depression  may  be  lessened  by  reading  cheerful  literature. 

Should  the  laryngeal  affection  be  unaccompanied  by  much 
infiltration  or  oedema,  the  patient  can  be  instructed  in  the 
method  of  intralaryngeal  heliotherapy,  directing  the  sun's 
rays  on  to  the  larynx  by  means  of  a  laryngeal  mirror  held  in 
position  by  himself.^  If  there  be  much  infiltration  of  the 
parts,  the  method  is  contra-indicated,  since  reactive  swelling 
will  follow  the  treatment  and  might  lead  to  dangerous 
dyspnoea.^* 

In  these  cases,  as  we  have  already  mentioned,  the  internal 
administration  of  creosote  or  guaiacol  is  often  helpful. 

In  regard  to  direct  treatment,  too  great  a  dilig^ence  in  the 
use  of  local  applications  to  the  larynx  is  to  be  deprecated,  and 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  699 

as  a  general  principle  topical  applications,  except  in  the  form 
of  soothing  sprays  or  inhalations,  are  better  avoided.  A 
simple  remedy  which  often  gives  relief,  by  removing  irritating 
secretion  from  the  upper  region  of  the  larynx,  is  a  spray  of 
Ems  water,  slightly  warmed  by  standing  in  a  tumbler  of  hot 
water.  In  certain  cases,  however,  when  there  is  persistent 
swelling  and  infiltration  of  the  larynx,  which  does  not  yield  to 
the  simpler  methods  of  treatm_ent  which  we  have  sketched  out, 
puncture  with  the  galvano-cautery  in  one  or  more  situations 
may  be  sanctioned,  with  a  view  to  induce  sclerosis  of  the 
adjoining  parts  and  thus  imitate  Nature's  method  of  healing. 
We  have  seen  benefit  from  this  procedure,  and  carefully  car- 
ried our,  have  not  known  it  lead  to  harm. 

The  free  curetting  of  ulcerated  surfaces  sometimes  practised 
is  not  a  method  of  treatment  which  we  can  recommend ;  we 
have  known  rapid  spread  of  the  pulmonary  disease  and  death 
to  follow  such  a  procedure.  The  plan  also  of  treating  ulcers 
of  the  larynx  by  the  direct  application  of  lactic  acid,  50-75  per 
cent.,  formerly  so  much  employed,  has  of  late  fallen  out  of 
favour  as  not  being  in  harmony  with  modern  methods  of 
treatment. 

If  the  ulceration  be  extensive  and  diffused,  palliative  treat- 
ment is  as  a  rule  alone  possible.  When  there  is  much  pain  the 
persistent  use  of  external  counter-irritation  will  be  found 
most  beneficial,  especially  when  combined  with  that  complete 
rest  to  the  larynx  which  pain  always  calls  for.  A  small  blister, 
the  size  of  a  shilling,  should  be  daily  appHed  over  the  region 
of  the  larynx  for  several  days,  so  as  to  keep  up  constant,  but 
not  too  severe,  counter-irritation. 

Perhaps,  however,  the  most  distressing  symptom  which 
attends  advanced  tuberculous  laryngitis  is  dysphagia,  which  so 
often  follows  ulceration  of  the  epiglottis.  This  may  be 
reheved  by  the  application  of  a  10  per  cent,  solution  of  cocaine 
to  the  throat,  or  by  allowing  gelatine  lozenges,  containing 
5  per  cent,  of  the  drug  slowly  to  dissolve  in  the  mouth  shortly 
before  meals.  Burroughs  Wellcome's  or  Oppenheimer's 
atomiser,  charged  with  parolein  and  cocaine  (5  per  cent.),  with 
a  little  morphine  or  chloral,  will  also  afford  great  relief  i 


m 


many  cases.  In  others  an  insufflation,  composed  of  iodoform 
and  boric  acid  (gr.  i  of  each),  and  morphine  acetate  (gr.  i), 
may  be  recommended. 


700  DISEASES   OF   THE  LUNGS   AND   PLEURA 

Orthoform  is  another  preparation  which  we,  in  common 
with  other  observers,  have  found  very  valuable  in  these  cases. 
It  is  a  synthetic  product  analog'ous  to  cocaine,  but  without  its 
toxic  defects;  it  relieves  the  pain  very  decidedly  in  many 
cases,  and  seems  to  produce  no  injurious  results.  The  remedy 
may  therefore  be  entrusted  to  the  patients  themselves,  who 
should  be  directed  to  place  a  little  of  the  powder  on  the  palm 
of  the  hand,  then  cover  it  with  the  broadened  end  of  a  Leduc's 
auto-insufflator*  (Fig.  65),  the  other  end  of  which  has  been 
previously  placed  in  the  mouth  and  hooked  over  the  back 
of  the  tongue;  a  deep  breath  is  then  taken,  when  the  inhaled 
air  draws  the  powder  through  the  tube,  and  distributes  it 
over  the  surface  of  the  larynx. 

If  there  be  much  inflammatory  secretion  over  the  ulcerated 
surfaces,  resorcin  may  be  added  to  the  orthoform  in  the  pro- 
portion of  resorcin  one  part,  orthoform  three  parts.     If  the 


Fig.  65. — A  Leduc's  Glass  Tube  for  the  Inhalation  of  Powders  into 
THE  Larynx  (Reduced  to  Half-Size). 

dysphagia  results  merely  from  swelling  of  the  larynx,  with- 
out ulceration  or  abrasion  of  the  surface,  orthoform  is  of  less 
value.  In  such  cases  insufflations  of  another  synthetic  pro- 
duct of  a  similar  order,  ancssthesin,  used  in  the  same  manner 
as  orthoform,  will  often  prove  successful. 

When  the  pain  in  swallowing  is  severe,  an  injection  of 
alcohol  (about  i  c.c.  of  a  solution  consisting  of  2  grains  of 
hydrochloride  of  eucaine  B.  in  an  ounce  of  80  per  cent.  alcohoP) 
into  one  or  both  superior  laryngeal  nerves  often  gives  striking 
relief.  This  results  from  the  partial  anaesthesia  of  the  larynx, 
which  is  brought  about,  and  which  lasts  for  a  considerable  time. 

Patients  in  this  stag"e  sometimes  swallow  their  food  with 
greater  ease  when  lying"  on  one  side  or  on  the  back;  others 
again  swallow  best  when  lying  with  the  head  over  the  side 
of  the  bed,  and  sucking  the  liquid  through  a  tube  from  a  cup 

*  These  simple  and  inexpensive  glass  tubes,  which  the  patients  soon  learn 
to  use  with  ease,  may  be  obtained  from  Messrs.  Maw  and  Sons. 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  /OI 

placed  at  a  lower  level.  In  other  instances  nutrient  enemata 
should  supplement  for  a  time  the  ordinary  method  of  feed- 
ing; they  help  to  give  rest  to  the  diseased  parts,  and  lessen  the 
distressing  sense  of  exhaustion  from  which  the  patients  often 
suffer. 

When  extensive  ulcerative  destruction  of  the  vocal  cords  is 
present,  the  most  distressing  symptoms  arise  from  the  strain 
of  cough  and  the  mechanical  difficulty  of  expectorating. 
These  truly  terrible  symptoms  are  most  difficult  to  relieve. 
When  they  arise  a  few  drops  of  chloroform,  or  thirty  drops  of 
equal  parts  of  chloroform  and  menthol,  may  be  placed  on  a 
handkerchief  or  sprinkled  on  blotting-paper  in  a  wide-mouthed 
smelling-bottle  or  tumbler,  and  inhaled.  Finally,  recourse  must 
be  had  to  morphia  to  lessen  the  acuteness  of  the  distress. 

Tracheotomy  is  very  rarely  necessary  in  cases  of  tubercu- 
lous laryngitis.  Occasionally,  however,  the  swelling  of  the 
parts  becomes  so  extreme,  perhaps  from  superadded  septic 
inflammation,  that  it  cannot  be  avoided.  The  effect  of 
tracheotomy  is  to  render  expectoration  almost  impossible,  and 
hastens  rather  than  hinders  the  progress  of  the  case. 

Aphthous  Mouth  and  Throat  is  a  distressing  compHcation  of 
advanced  phthisis,  and  one  especially  apt  to  occur  in  cases 
associated  with  diarrhoea.  It  may  be  warded  off  for  a  long 
time  by  careful  cleansing  of  the  mouth  each  time  food  is  taken 
with  weak  boracic  lotion,  or  with  tepid  water,  just  made  pink 
with  toilet  Condy,  to  which  a  few  drops  of  eau-de-Cologne 
have  been  added.  A  weak  glycerine  of  thymol  lotion  is  also 
useful. 

Pregnancy  and  Lactation. — We  may  perhaps  consider  at 
this  point  the  effect  which  pregnancy  has  upon  tuberculosis 
of  the  lungs.  There  can  be  little  doubt  that  this  complication 
has  not  by  any  means  that  uniformly  bad  effect  upon  the  pul- 
monary disease  with  which  it  has  been  sometimes  credited. 

During  the  pregnancy  the  general  health  is  not  uncom- 
monly improved,  and  we  have  known  patients,  the  subject  of 
quiescent  disease,  go  through  more  than  one  confinement 
without  any  harmful  result.  More  than  ordinary  care  must, 
of  course,  be  taken  in  regard  to  rest  and  diet  during  the 
period  of  gestation,  and  the  confinement  should  not  be 
allowed  to  be  unduly  prolonged.  In  such  cases  we  should 
not  interfere  in  any  way  with  the  pregnancy. 


702  DISEASES   OF   THE  LUNGS   AND   PLEURA 

It  is  later,  with  lactation,  that  the  danger  arises,  the  drain 
on  the  mother's  system  lowering  her  resistance  and  tending  to 
light  into  activity  the  pulmonary  disease.  It  is  our  practice, 
therefore,  to  forbid  the  suckling  of  the  child  by  the  phthisical 
mother  except  perhaps  for  the  first  few  days. 

It  is  well  also  to  bear  in  mind  that  though  the  danger  of 
preg"nancy  itself  may  have  been  exaggerated,  yet  a  large 
family  may  have  indirectly  a  bad  effect  upon  the  mother  in 
that  it  must  almost  certainly  mean  less  opportunity  for  rest 
and  for  that  careful  regulation  of  her  life  which  is  so  essential 
for  the  maintenance  of  arrest,  and  among-  the  poor  too  often 
also  insufficient  food.* 

Haemoptysis. — In  speaking-  of  the  treatment  of  haemoptysis, 
we  have  in  mind  the  causes  of  hsemorrhag'e  already  indicated 
as  operative  in  phthisis — viz.,  active  hyperasmia,  diseased  small 
vessels,  and  erosion  or  aneurismal  dilatation  of  large  vessels. 
The  two  former  conditions  account  for  most  attacks  of 
primary  hsemoptysis  and  for  such  intercurrent  attacks  as  are 
preceded  by,  or  attended  with  the  symptoms  and  signs  of 
fresh  accession  of  lung  disease;  the  latter  condition  being 
answerable  for  the  severe  and  sometimes  fatal  haemorrhage 
proceeding  from  cavities,  most  commonly  in  the  later  stages 
of  the  disease. 

Primary  and  Intercurrent  Hcemoptysis. — Shock  is  a  marked 
symptom  in  early  haemoptysis,  especially  in  first  attacks.  The 
agitation  of  the  patient  must  be  calmed  by  the  confident  assur- 
ance of  the  absence  of  immediate  danger,  and  all  measures 
of  treatment  should  be  carried  out  without  bustling  about 
or  whispering.  The  doctor  will  often  treat  his  patient  best 
by  quieting  anxious  friends.  The  recumbent  posture,  with 
head  and  shoulders  slightly  raised  by  pillows,  should  be 
adopted,  with  light  coverings  and  warmth  to  the  feet.  Ice 
should  be  given,  and  all  stimulating  restoratives  strictly  for- 
bidden. Indeed,  the  early  faintness  which  so  commonly  super- 
venes, when  short  of  actual  syncope,  should  be  encouraged 
rather  than  prevented,  since  it  involves  a  low  tension  in  the 
pulmonary  system,  a  condition  favourable  to  the  formation  of 
a  clot,  which  may  close  the  bleeding  vessel. 

In  all  cases  of  hsemoptysis  the  aspect  of  the  patient  and 
character  of  pulse  should  be  noted,  the  temperature  taken, 
and  the   stethoscope   lightly  applied   over  the   front   of  the 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  703^ 

chest,  no  extra  effort  of  breathing  being  allowed;  the  heart's 
sounds  should  also  be  carefully  listened  to.  All  these  observa- 
tions can  be  made  without  disturbing  the  patient  in  the  least, 
and  information  as  to  the  attack  can  be  gained  from  friends. 

There  are  different  types  of  cases  to  be  observed,  for  which 
different  plans  of  treatment  are  indicated.  In  a  considerable 
proportion  of  cases  there  is  pallor,  with  drawn  features,  chilly 
surface,  and  small,  thready,  quick  pulse,  significant  of  com- 
bined nervous  shock,  loss  of  blood,  and  constitutional  feeble- 
ness. In  such  cases  opium  is  of  great  value,  a  small  hypo- 
dermic injection  of  morphia  rapidly  calming  the  agitation 
and  quieting  the  heart's'  action.  It  must  be  administered, 
however,  with  caution,  and  not  in  sufficiently  large  doses  to 
check  all  cough,  lest  the  danger  of  broncho-pneumonia  from 
the  retention  of  infected  material  be  aggravated.  The  bowels 
should  be  attended  to,  and  later  may,  if  necessary,  be  kept 
freely  open,  the  pressure  of  the  blood  in  the  general  and  also 
in  the  pulmonary  circulation  being  thus  controlled.  For  this 
purpose  a  drachm  of  sulphate  of  magnesium,  three  or  four 
times  a  day,  may  be  prescribed.  For  some  days  the  patient 
must  be  kept  absolutely  at  rest  in  bed,  not  being  allowed  to 
rise  on  any  pretext,  and  not  encouraged  to  talk  by  the  visits 
of  sympathising  friends.  His  food  should  be  Hght,  and 
should  consist  of  two  to  three  pints  of  cold,  or  at  least  only 
just  warm,  milk  each  day,  with  a  little  bread  and  butter, 
junket  or  custard.  If  he  desires  it,  he  may  be  allowed  some 
ice  to  suck. 

Under  this  treatment  the  haemorrhage  will  often  cease; 
should  it  continue,  other  remedies  must  be  considered,  but  in 
g'auging  their  value  we  must  remember  that  cases  of  primary 
haemoptysis  as  a  rule  subside  without  much  trouble,  and  any 
remedy  used  in  a  sufficiently  large  number  of  cases  will  gain 
a  reputation.  Salt  and  water  was  long  held  by  the  Brompton 
nurses  as  of  great  efficacy. 

Of  the  special  remedies  of  value,  the  nitrites  may  first  be 
mentioned.  The  inhalation  of  amyl  nitrite  leads  to  the  dila- 
tation of  the  peripheral  vessels,  and  thus  to  a  lowering  of 
tension  in  both  general  and  pulmonary  systems.  So  much  is 
this  the  case  that  in  the  experiments  upon  dogs  of  MM.  Pic 
and  Petitjean^  the  lungs  became  white  and  anaemic  within  two 
or  three  minutes  of  the  amyl  nitrite  injection,  and  according 


704  DISEASES   OF  THE  LUNGS   AND  PLEURA 

to  these  observers,  if  a  cut  was  made  in  the  organ  at  the 
moment  of  the  injection,  the  copious  haemorrhage  resulting 
was  stanched  as  though  by  the  application  of  a  ligature.  The 
effect  was  said  to  last  about  five  minutes.  Amyl  nitrite  is 
thus  usefully  inhaled  at  the  first  onset  of  the  hsemorrhag'e, 
the  anaemia  of  the  lung  and  the  fall  in  pulmonary  pressure 
assisting  in  the  formation  of  a  clot,  and  sealing  the  bleeding 
point.  A  patient  who  has  had  haemoptysis  may  be  advised 
to  carry  the  capsules  in  his  pocket,  to  be  used  in  the  event  of 
any  emergency  arising.  The  effect  is,  however,  transitory, 
and  if  the  blood-pressure  is  estimated  to  range  above  the 
normal,  two-grain  doses  of  sodium  nitrite  may  often  be 
usefully  employed  to  ease  it  to  a  lower  level.  Erythrol 
tetranitrate  or  nitro-glycerine  may  be  prescribed  for  the 
same  end. 

In  certain  cases  five-grain  doses  of  ipecacuanha,  repeated 
every  one  or  two  hours  for  a  few  doses,  as  recommended  by 
Sir  Robert  Philip,  prove  valuable.  We  have  ourselves  never 
been  tempted  to  adopt  Trousseau's  plan  of  giving  an  emetic 
to  arrest  haemoptysis. 

Oil  of  turpentine  is  another  remedy  which  is  often  found 
useful,  although  its  mode  of  action  is  not  clear.  It  should 
be  given  in  twenty-minim  doses  every  four  hours,  and  may 
be  combined  with  three  minims  of  oil  of  cloves,  two  drachms 
of  mucilage  of  acacia,  and  cinnamon  water  to  one  ounce,  care 
being  taken  to  examine  the  urine  from  time  to  time  during  its 
administration  for  the  presence  of  albumin. 

Many  other  drugs  have  been  recommended  for  haemoptysis. 
Thus,  calcium  chloride  and  calcium  lactate,  in  doses  of  ten 
to  fifteen  grains  three  times  a  day,  have  been  thought 
by  some  observers  to  increase  the  coagulability  of  the 
blood,  and  to  be  thus  indicated.  We  have  tried  them 
on  many  occasions,  and  in  more  frequent  and  larger 
doses  than  the  above,  but  have  not  convinced  ourselves  of 
their  utility.  In  former  days  tannic  and  gallic  acid  and  acetate 
of  lead  were  also  much  employed,  but  a  study  of  their  phar- 
macological action  renders  it  more  than  doubtful  whether 
they  possess  that  remote  astringent  and  haemostatic  effect 
with  which  they  were  once  credited.  Their  astringent  action 
on  the  bowel  is  directly  opposed  also  to  the  requirements  of 
the  case.     We  have  found  tincture  of  hamamelis  (nixl.)  in 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  705 

combination  with  a  like  dose  of  hydrobromic  acid  every  six- 
hours  of  a  certain  value  in  cases  of  haemoptysis  when  the  first 
outburst  has  passed. 

Another  remedy  which  formerly  enjoyed  a  great  reputation 
is  ergot,  given  at  first  in  a  full  dose  (one  or  two  drachms  of 
the  liquid  extract  in  iced  water),  and  twenty  to  thirty  minims 
every  hour  afterwards  for  a  few  doses.  The  action  of  this 
drug'  is  to  stimulate  organic  muscle,  including  that  of  the 
arterioles;  but  whilst  thus  constricting  small  vessels,  it  at  the 
same  time,  as  shown  by  the  late  Dr.  Andrew,  raises  both  pul- 
monary and  systemic  blood-pressures,  and  any  good  effect 
upon  the  pulmonary  arterioles  is  thus  to  some  extent  coun- 
teracted. Nevertheless,  we  have  known  it  apparently  instru- 
mental in  arresting  haemoptysis  in  cases  in  which  other  reme- 
dies had  failed. 

More  recently  adrenalin  has  been  advocated  with  the  idea 
of  constricting  the  pulmonary  vessels,  and  thus  closing  the 
bleeding  point;  but  Drs.  Brodie  and  Dixon"  have  shown  it  to 
be  not  capable  of  producing  this  result,  and  Dr.  Langdon 
Brown^  records  that  "in  an  animal  killed  by  a  fatal  dose,  while 
all  the  other  tissues  were  anaemic — from  the  general  peri- 
pheral constriction — the  coronary  vessels  were  distended  with 
blood,  and  the  lungs  showed  a  condition  of  the  most  intense 
congestion,  being  a  deep  plum  colour."  Its  use  is  therefore 
contra-indicated. 

The  continuous  application  of  ice  to  the  chest  for  early  or 
intermittent  haemoptysis,  a  remedy  much  used,  is  in  our  opinion 
to  be  deprecated.  We  have  never  observed  it  to  do  good, 
and  have  seen  cases  in  which  it  appeared  to  do  much 
harm. 

For  the  haemoptysis  which  sometimes  occurs  in  persons 
with  venous  plethora  and  males  of  intemperate  habits,  and 
which  not  uncommonly  ushers  in  a  rapid  inflammatory  form 
of  phthisis,  a  drachm  of  sulphate  of  magnesium,  with  fifteen 
minims  of  aromatic  sulphuric  acid,  may  be  prescribed  with 
advantage  every  four  hours  until  the  secretions  become  free 
and  watery,  and  in  some  cases  it  is  well  to  begin  with  a  mer- 
curial. In  very  exceptional  cases  of  this  kind  depletion  from 
the  arm  may  be  advised. 

In  patients  in  whom  there  is  distinct  evidence  of  syphilitic 
cachexia  full  doses  of  iodide  of  potassium,  with  or  without 

45 


^o6  DISEASES   OP   THE  LUNGS   AND   PLEURA 

mercury,  should  be  combined  with  the  more  usual  methods  of 
treatment.  In  these  cases  the  haemoptysis  is  sometimes  very 
severe,  and  yet  yields  readily  to  treatment. 

In  the  early  stages  of  phthisis,  as  we  have  seen,  active 
inflammatory  hyperaemia  is  commonly  present,  and  may  give 
rise  to  haemorrhage,  which  does  not  usually  amount  to  more 
than  a  coloration  or  streaking  of  the  sputum.  The  recum- 
bent position  of  the  patient  during  sleep  is  a  factor  tending 
to  increase  the  hyperaemia,  and  if  the  head  and  shoulders  be 
raised  to  an  angle  of  45  degrees  with  the  trunk,  the  haemop- 
tysis will  in  some  cases  cease. ^ 

Slight  staining  of  the  expectoration,  or  even  a  small  quan- 
tity of  fresh  blood,  not  infrequently  appears  during  the 
eliminative  periods  of  the  pneumonic  forms  of  phthisis.  Such 
occurrences  need  occasion  no  modification  of  treatment,  being 
due  to  the  breaking  across  of  trabecular  vessels  of  small  size, 
already  partially  occluded.  As  a  matter  of  precaution  stricter 
quietude  must  be  enjoined  for  a  short  time  after  any  such 
occurrence.  Mixed  sanguineous  expectoration  in  cavity  cases 
is  best  combated  by  free  counter-irritation  by  the  application 
of  a  blister,  and  subsequently  dressing  the  surface  with  savin 
ointment  for  a  week  or  ten  days. 

Summary. — In  an  ordinary  case  of  primary  haemoptysis  our 
treatment,  therefore,  would  be  to  reassure  the  patient  and  his 
friends,  to  give  a  dose  of  morphia,  and  later  some  such  slight 
astringent  as  tincture  of  hamameHs,  in  combination  with 
hydrobro^mic  acid  in  iced  water.  If  amyl  nitrite  be  at  hand  it 
should  be  inhaled  during  the  attack.  Should  the  haemorrhage 
be  more  severe  and  repeated,  small  doses  of  nitrite  of  sodium 
may  be  given  for  a  couple  of  days  to  ease  the  blood-pressure. 
In  other  cases  in  which  the  haemorrhage  continues,  whilst  the 
blood-pressure  is  low,  turpentine  or  erg'ot  may  be  prescribed. 
The  patient  should  be  kept  at  absolute  rest,  and  the  diet 
should  consist  of  cooled  liquids,  and  such  semi-solids  as  cus- 
tard, blancmange,  and  bread  and  butter.  We  should  soon, 
however,  begin  cautiously  to  feed  our  patient,  avoiding  only 
hot  fluids.  It  is  of  the  utmost  importance  that  the  bowels 
should  be  kept  clear,  and  in  certain  cases  attended  with 
plethora  sulphate  of  magnesia  and  dilute  sulphuric  acid  are 
the  best  medicines.  Under  this  treatment  the  haemorrhage 
is  as  a  rule  quickly  controlled,  and  we  have  never  known  it 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  707 

necessary  in  the  class  of  case  which  we  are  now  considering, 
to  resort  to  artificial  pneumothorax. 

Recurrent  Hcsmoptysis. — In  the  treatment  of  this  form  of 
haemoptysis,  which,  it  will  be  remembered,  is  generally  due  to 
the  rupture  of  an  aneurism  in  a  pulmonary  cavity,  the  same 
general  principles  which  we  have  already  sketched  out  must 
be  adhered  to.  Absolute  rest  must  be  insisted  upon,  cough 
and  excitement  allayed  by  opium,  and  arterial  tension  reduced 
by  nitrites,  saHnes,  or  the  other  remedies  to  which  we  have 
alluded.  In  this  way  Nature  is  assisted  in  forming  a  coagu- 
lum  at  the  seat  of  rupture,  and  the  haemorrhage  is  checked. 

The  tendency  to  recurrence  of  haemorrhage  in  these  cases 
must  be  remembered,  and  care  must  be  taken  not  to  allow  the 
patients  to  move  about  too  soon.  In  those  patients,  too,  who 
are  gifted  with  rapid  blood-making  powers,  and  who  pick  up 
flesh  with  great  rapidity  after  haemoptysis,  a  judicious  ab- 
stinence from  butcher's  meat  and  the  complete  withdrawal  of 
stimulants  may  ward  off  or  postpone  the  next  attack. 

The  haemorrhage  in  this  form  is  far  more  profuse  than  in 
primary  haemoptysis,  and  is  often  immediately  fatal.  In  some 
instances,  as  in  that  of  the  patient  whose  case  we  have  re- 
corded (p.  553),  it  recurs  again  and  again,  until  the  patient 
arrives  at  the  lowest  ebb  compatible  with  life,  when  the  bleed- 
ing vessel  is  stanched  by  coagulum,  and  recovery  commences. 
In  some  other  cases,  however,  the  patient  dies  suddenly  from 
combined  syncope  and  blocking-  of  the  air-passages,  with  the 
expectoration  of  only  a  very  small  amount  of  blood. 

It  is  in  this  class  of  case,  in  which  the  haemoptysis  is  severe 
and  repeated,  and  the  patient's  life  in  danger,  that  treatment 
by  artificial  pneumothorax  is  of  value  (see  Chapter  LI.).  By 
this  means  the  lung  is  collapsed,  pressure  is  exerted  upon  the 
bleeding-  point,  and  the  formation  of  clot  facilitated.  We  have 
known  several  cases  thus  successfully  treated,  and  have  no 
hesitation  in  advising-  the  performance  of  the  operation  pro- 
vided we  can  be  reasonably  satisfied,  from  the  physical  signs 
and  symptoms,  as  to  the  side  from  which  the  haemorrhage  is 
proceeding.  It  -  sometimes  happens,  however,  that  with 
advanced  disease  in  one  lung",  the  patient's  sensations  tell  him 
that  the  blood  is  coming  from  the  other  and  less  affected  lung, 
and  this  is  not  impossible,  for  in  rapidly  advancing  cases  we 
have  known  aneurism  to  form  in  the  lung  much  less  exten- 


708  DISEASES   OF  THE  LUNGS   AND   PLEURAE 

sively  diseased.  Under  such  circumstances  the  treatment 
must  be  abandoned,  the  extensive  involvement  of  the  other 
lung  forbidding  us  to  entertain  the  idea  of  compressing  the 
more  healthy  side. 

With  reference  to  prophylactic  treatment,  patients  suffering 
from  phthisis,  who  have  chronic  cavities,  and  have  had  warn- 
ings of  haemoptysis,  should  be  cautioned  against  unnecessary 
and  especially  sudden  muscular  efforts  calculated  rapidly  to 
raise  the  blood-pressure,  and  should  therefore  avoid  hurry- 
ing upstairs,  walking  fast,  hastening  to  catch  trains,  and  so 
forth. 

Spurious  HcBinoptysis.  We  have  dealt  with  the  treatment 
of  this  non-pulmonary  form  of  haemorrhage  in  the  chapter 
devoted  to  its  description  (see  p.  557). 

Yomiting  with  Cough. — This  distressing  symptom  is  espe- 
cially characteristic  of  the  more  indurative  forms  and  stages 
of  the  disease,  and  its  successful  treatment  is  attended  with 
much  difficulty.  The  symptom  is  primarily  due,  as  we  have 
pointed  out  (p.  516),  to  the  mechanical  difficulty  in  expelling 
secretions  from  cavities  and  bronchial  tubes  which  are  sur- 
rounded by  dense,  tough,  airless  consolidations;  and,  secondly, 
it  is  distinctly  to  be  observed  in  many  cases  that  there  is 
undue  irritability  of  the  vagus,  giving  rise  to  cough  directly 
food  is  taken  into  the  stomach.  Any  catarrhal  condition  of 
this  organ  must  be  treated  by  alkalies,  bismuth,  and  hydro- 
cyanic acid  taken  an  hour  before  meals,  and  even  in  the 
absence  of  catarrh  this  alone  may  relieve  the  symptom  by 
rendering  the  mucous  membrane  less  responsive  to  nervous 
influences.  A  mixture  containing  five  grains  of  Alum,  five 
minims  of  Liquor  Potassae,  and  Peppermint  water  to  an  ounce, 
is  also  sometimes  helpful  in  these  cases.  If  there  appears  to 
be  a  hyperaesthetic  condition  of  the  vagus,  a  little  hydrocyanic 
acid  with  ten-minim  doses  of  the  Liquor  morphinae  hydro- 
chloridi,  taken  half  an  hour  before  the  principal  meals,  either 
alone  or  with  bismuth  and  soda,  may  succeed  in  preventing 
the  cough.  In  other  cases,  again,  we  have  found  a  course  of 
strychnia  as  a  nerve  tonic  of  value."  The  patient  should  keep 
strictly  at  rest  for  an  hour  or  so  after  meals. 

Intercurrent  Pleurisy.— Intercurrent  pleurisy  at  the  upper 
half  of  the  chest  is  best  treated  by  the  appHcation  of  small 
bhsters  or  the  Liquor  Epispasticus.     If  the  pain  be  rather  of 


TREATMENT   OF   PULMONARY   TUBERCULOSIS  709 

a  dull  aching  than  of  a  sharp  pleuritic  character,  and  if 
physical  signs  point  to  the  presence  of  fresh  pulmonary 
trouble,  the  more  gradual  effect  of  iodine  applications  is  to  be 
preferred.  The  Tinctura  iodi  fortis  should  be  painted  over  the 
part  each  day  or  second  day  for  two  or  more  applications,  a 
layer  of  pine-wool  covered  with  oiled  silk  being'  kept  con- 
stantly applied  over  the  part  painted.  It  must  be  remem- 
bered that  some  skins  are  much  more  sensitive  to  iodine  than 
others,  and  in  such  cases,  and  especially  in  children,  the  Tinc- 
tura iodi  mitis  will  be  found  sufficiently  strong. 

When  some  portion  of  the  lower  half  of  the  chest  is  affected 
with  pleurisy  in  the  course  of  phthisis,  the  prompt  apphcation 
of  a  long  piece  of  Leslie's  strapping  three  or  four  inches 
broad,  so  as  to  extend  round  the  affected  side  to  a  couple  of 
inches  beyond  the  median  Hne  in  front  and  behind,  will,  by 
restraining  respiratory  movements,  at  once  relieve  pain,  and 
often  arrest  the  local  inflammation.  This  treatment  is  of 
great  value  in  many  cases,  and  is  to  be  particularly  advised 
when,  in  addition  to  the  signs  of  pleurisy,  superficial 
crepitations  with  a  few  liquid  clicks  suggest  that  liquefac- 
tion of  caseous  pneumonic  centres  is  proceeding  close  under 
the  pleura.  The  timely  apphcation  of  strapping  in  such 
cases  may,  by  relieving  the  lung  from  the  shock  of  cough, 
avert  pneumothorax.  Some  patients  cannot  bear  this  appli- 
cation, however,  and  the  rough  clinical  test  of  its  probable 
usefulness  in  any  given  case  is  to  hold  the  side  with  steady 
pressure  of  the  hand,  and  see  whether  relief  from  pain  is 
thereby  obtained.  When  strapping  is  not  tolerated,  the  apph- 
cation of  a  few  leeches,  or  a  small  bhster,  with  a  hot  hnseed 
poultice  over  it,  will  speedily  give  rehef,  and  this  line  of  treat- 
ment may  be  followed  with  advantage  when  the  pain  is 
severe. 

Tuberculous  Meningitis.— The  early  stages  of  tuberculous 
meningitis  are,  as  already  pointed  out  (p.  563),  very  insidious 
and  obscure,  and  it  must  be  confessed  that  the  progress  of 
this  fatal  malady  is  beyond  our  control.  Some  of  its  more 
distressing  symptoms  may,  however,  be  mitigated.  A  brisk 
calomel  purge  should  first  be  given,  and  if  pain  in  the  head  be 
a  marked  symptom,  it  will  be  reheved  by  the  application  of 
cold  lotions  or  the  ice-cap.  In  severe  cases  relief  will  be 
afforded  by  the  apphcation  of  leeches  to  the  temples.     The 


710  .  DISEASES   OF   THE   LUNGS   AND   PLEURA 

room  should,  in  the  earHer  stages  of  the  disease,  be  darkened; 
care  must  be  taken  to  relieve  the  bladder  if  necessary. 

Full  doses  of  bromide  and  smaller  doses  of  iodide  of  potas- 
sium seem  sometimes  to  give  rehef.  When  twitchings  are 
present,  chloral  should  be  given  in  combination  with  the  bro- 
mide. Should  convulsions  threaten,  the  chloral  should  be 
sufficiently  pushed  to  avert,  if  possible,  this  symptom,  so  dis- 
tressing to  friends,  although,  happily,  unfelt  by  the  patient, 
the  remedy  being  administered  in  a  little  water  or  barley- 
water  by  the  rectum,  if  it  cannot  be  taken  by  the  mouth.  A 
few  whiffs  of  chloroform  sometimes  appear  to  restrain  con- 
vulsions. Considerable  relief  may  be  given  in  many  cases  by 
lumbar  puncture,  the  excess  of  fluid  effused  into  the  ventricles 
being  thus  drained  away,  and  pressure  symptoms  for  a  time 
relieved.    The  tapping  should  be  repeated  if  necessary. 

REFERENCES. 

*  [a)   La   Cure  de  Soldi,  par   Dr.   A.   Rollier,  pp.    171   and   154.     Paris- 

Lausanne,  1914. 
[b)  Loc.  cit.,  p.  184. 
^  "  Contribution   a   la    Pratique    de    Heliotherapie    Laryngee,"    par    R. 
Alexandre,  Archives  Internationales  de  Laryngologie,  d^Otologie,  et 
de  Rhinologie,  1912,  tome  xxxiii.,  p.  388. 

*  "  The  Treatment  of  the  Dysphagia  of  Laryngeal  Tuberculosis  by 
Alcohol  Injections  into  the  Superior  Laryngeal  Nerve,"  by  J.  Dundas 
Grant,  M.A.,  M.D.,  F.R.C.S.,  The  Lancet,  1910,  vol.  i.,  p.  1754. 

*  See  also  an  interesting  note  on  "  Pregnancy  and  Tuberculosis  of  the 
Lungs,"  British  Medical  Journal,  1915,  vol.  i.,  p.  348. 

°  (a)    "  De    Quelques    Applications    Nouvelles    de   la    Medication    Vaso- 
motrice  au  Traitement  des  Hemoptysies  d'Origine  Pulmonaire  chez 
les  Tuberculeux,"  par  MM.  A.  Pic  et  G.  Petitjean,  Lyon  Medical, 
1906,  tome  cvi.,  p.  309. 
[b]   "  Effets  compares  du  Nitrite  d'Amyle  sur  la  Grande  et  la  Petite 
Circulation,"   par    MM.    A.    Pic   et    G.    Petitjean,    Comftes   Rendus 
Hebdomadaires  des  Seances  et  Memoires  de  la  Societe  de  Biologie, 
1906,  tome  i.,  p.   131. 
'  "  Contributions   to  the   Physiology   of   the   Lungs,    Part    II.,    On   the 
Innervation   of   the   Pulmonary   Bloodvessels ;    and   Some  Observations   on 
the  Action  of  Suprarenal  Extract,"  by  T.   G.   Brodie,   M.D.,   and  W.   E. 
Dixon,  M.D.,  Journal  of  Physiology,  1904,  vol.  xxx.,  p.  476. 

''  Physiological  Principles  in  Treatment,  by  W.  Langdon  Brown,  M.D., 
p.  22.     London,   1908. 

*  "  The  Rational  Treatment  of  Capillary  Haemoptysis  in  Phthisis,"  by 
Charles  GaskeU  Higginson,  British  Medical  Journal,  1905,  voL  ii.,  p.  577. 

^  "  The  Use  of  Strychnia  in  the  Vomiting  of  Phthisis,"  by  R.  Douglas 
PoweU,  M.D.,  The  Practitioner,  1868,  vol.  i.,  p.  312. 


CHAPTER  L 

SPECIFIC  TREATMENT  OF  PULMONARY  TUBERCULOSIS 

We  have  in  the  preceding  chapters  considered  the  treatment 
which  should  be  adopted  in  dealing  with  the  various  forms  of 
pulmonary  tuberculosis.  Apart  from  the  combating  of  special 
symptoms,  the  lines  of  treatment  suggested  are,  broadly 
speaking,  designed  to  shield  the  patient  as  far  as  possible 
from  the  absorption  of  excessive  doses  of  toxines,  whilst  at 
the  same  time  his  vitality  is  stimulated  and  his  strength  sus- 
tained, and  the  formation  of  protective  substances  in  the 
blood  and  tissues  thus  increased.  We  have  now  to  discuss 
whether  there  is  any  specific  treatment  which  will  play  a  more 
direct  part  in  our  fight  against  the  disease. 

The  inhalation  of  bactericidal  sprays,  heated  air,  stable 
emanations,  compressed  and  rarefied  airs,  sulphuretted  hydro- 
gen, the  administration  of  sulphuretted  waters  and  gases  by 
the  mouth  and  per  rectum,  the  subcutaneous  injection  of  anti- 
septic drug's  of  all  sorts,  have  been  tried  by  able  and  sanguine 
observers,  but  the  results  obtained  have  not  been  such  as  to 
warrant  our  dwelling'  any  further  upon  them.  Many  of  these 
remedies  may  take  a  humbler  place  in  the  treatment  of  par- 
ticular symptoms,  but  none  have  the  slightest  value  as  specific 
measures  against  the  malady. 

The  fundamental  object  in  the  treatment  of  tuberculosis  is, 
as  already  explained,  to  obtain  immunity  to  tuberculous 
activity  by  fortifying  and  maintaining  resistance  to  further 
attack.  Vaccines  are  employed  in  acute  and  chronic  diseases 
of  infective  origin  with  the  object  of  securing-  immunity  by 
increasing  opsonic  and  other  antimicrobial  means  of  resistance 
and  stimulating  phagocytic  activity.  It  is  doubtful,  however, 
whether  they  are  of  value  in  the  acute  phase  of  any  illness, 
such  as  pneumonia,  scarlet  fever,  typhoid,  tuberculosis,  etc., 

711 


712  DISEASES    OF   THE   LUNGS   AND   PLEURAE 

for  in  this  phase  of  such  diseases  the  blood  is  already  over- 
whelmed with  the  toxines  from  the  microbic  activity  respon- 
sible for  the  disease.  Before  exposure  to  infection,  however, 
and  possibly  during  the  incubation  period  of  some  infective 
diseases,  an  appropriate  vaccine  may  be  of  value  by  artificially 
stimulating  resistance  to  the  toxine  in  question.  In  some 
chronic  infections  also,  when  resistance  has  reached  a  low 
ebb,  a  stimulating  reaction  may  be  thus  provoked  with 
advantage. 

Tuberculosis  is  a  malady  in  which,  during  its  acute  phases, 
the  svstem  is  already  more  than  adequately  charged  with 
toxines  from  the  bacillus.  In  the  sub-acute  and  chronic 
stag"es,  again,  there  are  always  patches  of  sub-active  bacillary 
lesions  or  centres  of  quiescent  disease,  for  the  most  part  not 
walled  off  from  the  general  lymphatic  system,  so  that  the 
patient,  if  we  may  so  express  it,  is  rather  "  over  salted  "  than 
otherwise,  and  it  is  only  necessary  to  flush  the  centres  of 
disease  by  an  excessive  activity  of  circulation  through  exer- 
cise, mental  excitement  or  anything  that  hurries  the  breathing 
and  heart's  action,  to  produce  such  an  extra  absorption  of 
tuberculous  toxine  from  the  lesions  as  shall  cause  a  reactive 
rise  of  temperature. 

Thus  is  explained  the  importance  in  tuberculosis  of  rest 
treatment  when  the  disease  is  active,  and  graduated  exercise 
treatment  when  the  disease  is  passive;  and  such  are  the 
grounds  on  which  doubt  is  cast  on  the  general  utiHty  of  tuber- 
culin in  this  disease,  and  on  which  an  insight  is  obtained  as 
to  how  immunity  is,  in  many  cases,  acquired. 

There  are,  however,  exceptional  cases  of  pulmonary  tuber- 
culosis and  of  local  tubercle  situated  in  other  parts  than  the 
lungs — as,  for  example,  in  bones,  in  glands  and  in  other 
positions — in  which  tuberculin  may  be  employed,  and  the 
following  are,  briefly,  in  such  cases  the  methods  to  be  pur- 
sued :  ' 

Varieties  of  Tuberculin. — Many  varieties  of  tuberculin  .are 
now  to  be  obtained  which  differ  from  one  another  in  their 
mode  of  preparation  and  in  their  chemical  features.  Clinically, 
however,  the  results  obtained  from  their  employment  are  not 
very  dissimilar.     The  more  important  are  the  following : 

I.  Old  Tuberculin — Tuherkulin  Alt. — This  was  the  prepara- 
tion used  by  Koch  in  1890  in  the  treatment  of  the  patients 


SPECIFIC   TREATMENT   OF   PULMONARY   TUBERCULOSIS      /1 3 

who  thronged  to  Berlin  in  that  memorable  year.  It  is  pre- 
pared from  a  culture  of  human  tubercle  bacilli  which  have 
been  grown  for  some  six  weeks  in  5  per  cent,  glycerine  broth. 
This  is  boiled  for  one  hour  to  kill  the  bacilli,  and  the  fluid 
concentrated  to  one-tenth  of  its  volume  by  evaporation  at 
a  temperature  not  exceeding  70°  C.  The  bacilli  are  then 
separated  off  by  filtration.  The  golden-brown,  somewhat 
viscid  liquid  thus  obtained  is  Old  Tuberculin,  which  contains 
the  toxines  which  are  soluble  in  50  per  cent,  glycerine. 
One  c.c.  of  this  preparation  is  regarded  as  equivalent  to  one 
gramme  (1,000  mgr.). 

2.  Alhumose-Free  Old  Tuberculin  (A.F.). — This  resembles 
Old  Tuberculin  in  all  respects  except  that  it  is  grown  upon  a 
proteid-free  medium,  contains  no  albumose  and  is  believed 
therefore  to  be  less  toxic  in  its  effects. 

3.  Denys'  Tuberculin — Bouillon  Filtre  (B.F.). — This  differs 
from  Koch's  Old  Tuberculin  only  in  the  non-concentration  of 
the  broth  culture.  The  culture  of  human  tubercle  bacilli  at 
the  end  of  six  weeks'  growth  is  filtered,  and  the  unboiled,  un- 
heated  filtrate  constitutes  Denys'  tuberculin.  Professor  Denys 
beheves  that  in  this  way  deterioration  of  the  toxines  is  pre- 
vented. 

4.  New  Tuberculin — Tuberculin  Rest  (T.R.)^ — This  is  pre- 
pared by  grinding  dried  human  tubercle  bacilli  in  an  agate 
mortar,  extracting  with  distilled  water,  and  centrifugalising. 
The  upper  layer,  called  by  Koch  "T.O."  (Tuberculin  Obersi), 
closely  resembles  Old  Tuberculin.  The  lower  layer,  or  re- 
mainder (Rest),  which  thus  contains  the  pulverised  and  par- 
tially extracted  bodies  of  the  bacilli,  is  suspended  in  water 
containing  20  per  cent,  glycerine  to  prevent  decomposition, 
and  constitutes  New  Tuberculin,  or  T.R.  Each  cubic  centi- 
metre contains  2  milligrammes  of  solid  matter  derived  from 
10  milligrammes  of  dried  bacilli.  T.R.  thus  differs  materially 
from  Old  Tuberculin,  which  contains,  as  we  have  seen,  not 
the  bacillary  bodies,  but  those  substances  derived  from  them, 
which  are  soluble  in  50  per  cent,  glycerine. 

5.  New  Tuberculin — Bacillary  Emulsion  (B.E.) — This  was 
introduced  by  Koch  in  1901,  and  consists  of  pulverised  human 
bacilli,  not  extracted  in  any  way,  but  suspended  in  equal  parts 
of  water  and  glycerine.  Each  cubic  centimetre  of  the  prepara- 
tion contains  5  milligrammes  of  soHd  matter. 


714  DISEASES   OF  THE  LUNGS    AND   PLEURA 

In  addition  to  the  above,  we  may  mention  the  Sensitised 
Bacillary  Emulsion  (S.B.E.)  and  Professor  Beraneck's  Ttiber- 
culin,  which,  with  many  other  varieties  of  tuberciiHn,  prepared 
in  different  ways,  some  from  human  and  some  from  bovine, 
strains  of  bacilli,  contain  different  proportions  of  the  intra- 
and  extracellular  toxines. 

Although  differing  in  their  composition  and  in  their  strength, 
all  varieties  of  tubercuHn  have  this  in  common,  that  they 
contain  undoubted  toxines,  and  that  by  their  use  an  attempt 
is  made  to  call  forth  an  active  response  on  the  part  of  the 
organism  and  an  increased  production  of  protective  sub- 
stances. The  process  aimed  at,  in  fact,  is  the  production  of 
an  active  immunisation,  in  which  the  cells  of  the  body  must 
play  their  part,  as  opposed  to  the  passive  role  assigned  to 
them  when  a  poison  within  the  body  is  neutralised  by  the 
introduction  of  an  antitoxic  serum. 

Of  the  above  varieties  of  tuberculin  the  New  Tuberculin 
(T.R.)  and  Denys'  Tuberculin  are  the  milder  preparations. 
With  all,  however,  the  clinical  effects  are  not  very  dis- 
similar, and  in  each  case  our  aim  should  be,  by  commencing 
with  very  small  doses,  and  by  increasing  the  dose  very  gradu- 
ally, to  avoid  the  production  of  any  clinical  "  reaction," 
whether  indicated  by  fever,  malaise,  pains  in  the  joints  or 
back,  increase  of  cough  and  sputum  or  other  manifestation. 
We  may  add  that  New  Tuberculin  (T.R.)  is  a  much  more 
expensive  preparation  than  the  Bacillary  Emulsion,  and  on 
this  ground  the  latter  is  to  be  preferred. 

Dosage. — Tuberculin  is  best  given  by  subcutaneous  injec- 
tion, -01  c.mm.  ( 100000  c.c.)  of  Old  Tuberculin,  A.F.,  T.R.,  or 
B.E.,  being  a  common  dose  with  which  to  commence.  The 
following  scheme  of  dosage,  on  the  lines  suggested  by  Drs. 
BandeHer  and  Roepke,^  we  have  found  useful  as  a  guide  in 
practice,  it  being  understood  that  in  the  event  of  any  clinical 
reaction  occurring  a  longer  interval  than  usual  must  be 
allowed  before  the  next  dose,  which  should  also  be  somewhat 
smaller  than  the  dose  which  caused  the  reaction.  Should  no 
reaction  follow  the  reduced  dose,  the  amount  of  tuberculin 
should  again  be  gradually  increased.  If  the  doses  are 
increased  too  rapidly,  a  condition  of  hypersusceptibility 
("  anaphylaxis  ")  to  the  tuberculin  may  be  developed,  which  it 
is  important  to  avoid. 


SPECIFIC   TREATMENT   OF   PULMONARY   TUBERCULOSIS      /1 5 

Scheme  of  Dosage  for  the  Administration  of  Tuberculin  (o.t.,  a.f., 
t.e.,  and  n.e.)  by  subcutaneous  injection. 

An  injection  to  be  given  every  alternate  day,  commencing  with  -ooi  c.mm. 
(a  millionth  of  a  c.c.)  and  proceeding  as  follows  : 

•OOI,  -003,  -006  c.mm. 
.•01,  "03,  -06  c.mm. 
•I,  -15.  -2,  -3,  -5,  -7  c.mm. 

Then  continue  with  an  injection  twice  a  week. 

I.  1-5.  2,  3,  5,  7  c.mm. 
10,  15,  20,  30,  50,  70  c.mm. 

Finally,  if  no  contra-indication  exists  and  time  allows,  an  injection  to  be 
given  once  a  week  as  follows  : 

100,  150,  200,  300,  400,  600,  800,  1,000  c.mm.  (i  c.c). 

The  maximum  dose  may  be  repeated  several  times  at  increasing  intervals. 

Cases  suitable  for  Treatment. — There  can  be  little  doubt, 
both  on  the  theoretical  grounds  already  hinted  at  (p.  712), 
and  in  view  of  the  practical  results  obtained  at  Mid- 
hurst,  to  which  we  shall  shortly  refer,  that  the  value 
of  tuberculin  as  a  remedial  agent  in  the  treatment  of 
phthisis  has  been  greatly  overestimated.  It  may,  however, 
still  be  prescribed  in  exceptional  circumstances.  It  may,  for 
example,  be  given,  when  other  treatment  has  failed,  in  qi.iies- 
cent  apyrexial  cases  in  which  improvement  has  proceeded  up 
to  a  point  and  then  come  to  a  halt,  or  in  cases  in  which,  in 
spite  of  a  stationary  and  fair  weight,  and  an  absence  of 
pyrexia,  the  pulmonary  disease  slowly  and  insidiously  extends. 
It  must  be  remembered  that  in  order  to  produce  a  good  result 
tuberculin  must  call  forth  an  active  immunising  response  on 
the  part  of  the  patient,  and  a  certain  degree  of  vitality  is 
therefore  essential  for  its  successful  administration.  In 
febrile  cases  the  remedy  is  contra-indicated,  the  reactive  power 
of  the  patient  being  already  stimulated  to  the  full  by  the 
excessive  doses  of  toxine  which  are  being  absorbed. 

Results  of  Treatment.— In  attempting  to  decide  upon  the 
value  of  tuberculin  in  the  treatment  of  phthisis,  we  must 
at  once  recognise  that  g'reat  caution  must  be  exercised  in 
basing  an  opinion  upon  individual  cases.  It  has  been  our  lot 
from  time  to  time  when  treating  cases  in  the  wards  to  be 
struck  with  the  improvement  shown  by  a  patient  receiving 
tubercuhn,  and  we  have  been  inclined  to  attribute  the  result 


7l6  DISEASES   OF   THE  LUNGS   AND   PLEURA 

to  the  specific  treatment,  until  a  few  beds  farther  on  we  have 
met  with  a  patient  in  an  almost  similar  condition  untreated 
by  tuberculin^  in  whom  the  improvement  has  been  equally 
rapid.  Had  the  first  patient  been  the  only  one  under  observa- 
tion, it  would  have  been  difficult  to  avoid  overestimating  the 
possible  value  of  the  remedy.  Our  experience  is  not  excep- 
tional. The  capacity  for  improvement  under  better  condi- 
tions of  feeding  and  hygiene  is  a  marked  feature  in  many 
phthisical  cases,  and  we  must  accordingly  gauge  the  result 
of  treatment  not  so  much  by  impressions  derived  from  indi- 
vidual patients,  as  by  a  careful  inquiry  into  the  effect  pro- 
duced in  a  large  series  of  cases,  and  by  the  permanency  of  the 
results  obtained. 

In  this  connection  we  must  refer  to  the  careful  investiga- 
tion in  regard  to  the  value  of  tuberculin  treatment  recently 
made  on  actuarial  lines  at  the  King  Edward  VII.  Sana- 
torium, Midhurst,  by  Dr.  Bardswell  and  Mr.  Thompson.^ 
These  observers  compared  the  results  obtained  in  384  male 
and  female  patients  belonging  to  groups  i  and  2  (incipient 
and  moderately  advanced  cases),  who  had  tubercle  bacilli  in 
the  sputum,  and  who  were  treated  at  the  sanatorium  over  a 
period  of  three  years,  during  which  sanatorium  methods  only 
were  employed,  with  a  series  of  352  comparable  cases  admitted 
during  the  three  succeeding  years,  when  tuberculin  was  also 
being  administered.  Of  these  352  cases  238  received  a  course 
of  tuberculin  in  addition  to  sanatorium  treatment.  If  tuber- 
culin were  an  efficient  aid  to  treatment,  its  value  should  be 
shown  by  an  improvement  in  the  general  results  obtained. 
The  tuberculin  used,  we  may  add,  was  almost  exclusively 
Albumose-Free  Old  Tuberculin  (A.F.)  and  Koch's  Bacillary 
Emulsion  (B.E.),  and  the  method  of  administration  that  of 
BandeHer  and  Roepke,  and  in  the  last  year  the  reactionless 
method  of  SahH  and  Trudeau,  both  of  them  methods  of  recog- 
nised repute. 

The  results  obtained  were  as  follows : 

(i)  hnmediate  Results. — The  condition  on  discharge  of  the 
patients  belonging  to  the  two  series  was  practically  the 
same,  the  percentage  of  those  recorded  as  "  arrested  or  much 
improved,"  "improved,"  "stationary  or  worse"  being  very 
similar. 

(2)  Sputum  Records. — The  percentage  of  patients  in  whom 


SPECIFIC  TREATMENT  OF  PULMONARY  TUBERCULOSIS      /I/ 

tubercle  bacilli  disappeared  from  the  sputum  during  treatment 
in  the  sanatorium  showed  a  close  agreement  in  the  two  series, 
26-3  per  cent,  of  the  patients  during  the  control  period,  who 
received  sanatorium  treatment  only,  losing  their  tubercle 
bacilli,  as  compared  with  267  per  cent,  of  those  treated  during 
the  tubercuHn  years.  This  point  is  of  importance  since,  as  we 
have  indicated  elsewhere  (p.  631),  patients  who  lose  their 
bacilli  during  treatment  at  the  sanatorium  have  a  better  prog- 
nosis than  those  in  whom  tubercle  bacilli  persist. 

(3)  Subsequent  Results. — With  regard  to  the  after-histories 
of  the  patients,  compared  in  each  case  up  to  four  years  after 
discharge,  it  was  found  that  the  ratio  of  "actual"  to  "ex- 
pected deaths  "  was  i8-o  per  cent,  for  the  patients  who  during 
the  control  period  received  sanatorium  treatment  only,  and 
iS'i  per  cent,  for  those  treated  during  the  tuberculin  period. 

These  results  show  that  tuberculin,  when  given  in  the 
manner  adopted  at  Midhurst,  and  as  an  adjunct  to  sanatorium 
treatment,  had  no  appreciable  effect,  either  favourable  or 
unfavourable. 

It  is  interesting  to  note  that  Messrs.  Elderton  and  Perry,* 
after  an  actuarial  study  of  the  valuable  data  from  the  Adiron- 
dack Sanitarium,  in  New  York  State,  arrived  at  a  somewhat 
similar  conclusion — namely,  that,  while  it  was  not  possible  to 
say  that  there  was  no  case  in  which  tuberculin  might  not  be  of 
use,  its  value  as  judged  from  the  subsequent  mortality  of  the 
patients  had  not  been  proved. 

It  is  clear,  therefore,  that  tuberculin  can  no  longer  be  re- 
garded as  having  the  specific  value  at  one  time  attributed  to  it, 
and  its  employment,  as  we  have  already  indicated,  must  be 
correspondingly  restricted. 

Serum-Therapy.— In  addition  to  the  method  of  active  im- 
munisation aimed  at  by  the  treatment  with  tubercuHn,  an 
attempt  has  been  made  to  effect  a  passive  immunisation  by 
means  of  serum-therapy,  whereby  protective  bodies  prepared 
in  other  animals  are  brought  to  the  immediate  assistance  of 
the  patient.  Of  such  sera  the  best  known  are  those  of 
Maragliano  and  of  Marmorek.  Neither  have,  however,  ful- 
filled the  hopes  with  which  they  were  introduced,  and  they 
are  now  but  little  used. 

The  Specific  Treatment  of  Mixed  and  Secondary  Infections 

In  an  earlier  chapter  (p.  467)  we  have  given  reasons  for  be- 


71 8  DISEASES   OF   THE  LUNGS   AND   PLEURA 

lieving  that  in  certain  rapidly  progressing  cases  of  phthisis 
the  fever  and  the  spread  of  the  disease  are  due  in  part  to  the 
agency  of  organisms  other  than  the  tubercle  bacillus,  and 
attempts  have  been  made,  by  isolating  such  organisms  from 
the  sputum  and  producing  appropriate  vaccines,  to  cut  short 
their  activity,  to  the  relief  of  the  patient  and  the  improvement 
of  his  symptoms.  The  results  have,  however,  been  disap- 
pointing, and,  as  we  have  already  pointed  out,  but  little  must 
be  hoped  from  vaccines  in  the  acute  stages  of  the  disease, 
when  the  body  is  already  receiving  excessive  doses  of  the 
microbial  poisons.  More  perhaps  may  be  expected  in  chronic 
cases  in  checking  excessive  cough  and  bronchial  excretion, 
which,  as  we  have  seen,  are  often  the  result  of  secondary 
infection  by  pathogenic  organisms. 

REFERENCES. 

^  "  Ueber  Neue  Tuberkulin  Praparate,"  von  Robert  Koch,  Deutsche 
Medicinische  W ochenscJirijt,   1897,   No.    14,  p.  209. 

^  Lehrbuch  der  Sfezifischen  Diagnostik  und  Therafie  der  Tuberkulose 
jiir  Arzte  und  Studierende  5  Auflage,  von  Dr.  Bandelier  (in  Schomberg 
bei  Wildbad)  und  Dr.  Roepke  (in  Melsungen).     Wiirzbur^,   1913. 

^  "  Pulmonary  Tuberculosis  :  Mortality  after  Sanatorium  Treatment," 
by  Noel  D.  BardsweU,  M.V.O.,  M.D.,  F.R.C.P.,  and  John  H.  R. 
Thompson,  F.I. A.,  Medical  Research  Committee  Re-port.     London,   1919. 

^  "  A  fourth  Study  of  the  Statistics  of  Pulmonary  Tuberculosis  :  the 
Mortality  of  the  Tuberculous  :  Sanatorium  and  Tuberculin  Treatment," 
by  W.  Palin  Elderton,  F.I. A.,  and  Sidney  J.  Perry,  A. I. A.,  Drapers'  Com- 
pany Research  Memoirs.     London,  1913. 


CHAPTER  LI 

TREATMENT    OF    PULMONARY    TUBERCULOSIS    BY 

(i)  ARTIFICIAL  PNEUMOTHORAX,  (2)  SURGICAL 

INTERVENTION 

Artificial  Pneumothorax. 

In  the  preceding  chapters  we  have  discussed  the  hygienic 
and  climatic  treatment  of  pulmonary  tuberculosis,  the  use  of 
tubercuHn,  and  the  value  of  drugs.  In  certain  cases  of  a 
fairly  well-defined  kind,  in  which,  in  spite  of  all  efforts,  the 
disease  makes  progress,  and  especially  in  some  in  which 
recurrent  haemoptysis  is  a  well-marked  feature,  the  question 
of  inducing  an  "  artificial  pneumothorax  "  presents  itself,  and 
must  now  be  considered. 

By  this  method  air  or  gas  is  introduced  under  strict  anti- 
septic precautions  into  the  pleural  cavity  by  means  of  a 
special  apparatus,  and  the  lung  is  collapsed,  thus  rendering 
it  passive,  allowing  active  lesions  to  cicatrise  and  heal, 
while  at  the  same  time  absorption  of  toxine  is  lessened.  If 
there  has  been  haemorrhage,  the  pressure  tends  to  prevent  its 
recurrence.  In  the  earlier  days  of  the  treatment  nitrogen 
was  the  gas  employed,  but  experience  has  shown  that  it 
possesses  no  advantage  over  air,  which  is  not  absorbed  more 
quickly,  and  air  is  now  commonly  used.  The  practice  of 
introducing  oxygen  at  the  first  injection,  with  a  view  to 
diminish  the  risk  of  gas  embolism,  appears  to  be  based  upon 
a  misconception  and  to  possess  no  practical  advantage. 

The  experiment  was  apparently  first  made  by  the  late 
Dr.  Cayley  in  the  year  1885  ^^  ^  case  of  haemoptysis,  to  which 
we  have  already  referred,  the  pneumothorax  in  this  instance 
being  produced  by  incision  through  the  chest  wall.  For  the 
modern  developments  of  the  method  and  its  present  technique 
we  are  indebted  especially  to  Professor  Forlanini  of  Pavia, 
Professor  Brauer  of  Hamburg,  and  Professor  Saugman  of 

719 


720  DISEASES   OF   THE  LUNGS   AND   PLEURAE 

Vejlefjord  in  Denmark,  and  in  this  country  to  Dr.  Clive 
Riviere/  to  whose  work  we  may  refer  the  reader  for  many 
technical  details. 

Technique. — For  the  introduction  of  the  air  some  simple 
portable  apparatus  is  required.  Several  have  been  intro- 
duced, among  which  we  may  mention  that  of  Dr.  W.  Parry 
Morgan,^  but  the  one  devised  by  Dr.  Lillingston  and 
Dr.  Vere  Pearson^  may  be  recommended  as  simple  and 
eifective,  and,  with  some  slight  modifications,  is  now  in  use 
at  the  Brompton  Hospital  (Plate  XXXIII.).  It  consists  of  a 
needle  connected  by  rubber  tubing  to  a  bottle  containing  air, 
the  "  gas  bottle,"  and  by  means  of  a  cross-piece  with  a  mano- 
meter, whereby  the  pleural  pressure  is  measured.  The  gas 
bottle  itself  is  connected  with  a  "pressure  bottle"  containing 
a  coloured  antiseptic  solution,  such  as  i  in  i,ooo  perchloride, 
by  the  lowering  or  raising  of  which  the  outflow  of  gas  into 
the  pleural  cavity  can  be  regulated.  Between  the  needle  and 
the  cross-piece  connecting  with  the  manometer  a  piece  of 
glass  tubing  containing  sterilised  cotton-wool  for  filtering  the 
air  is  inserted,  and  a  second  between  the  cross-piece  and 
the  gas  bottle.  It  is  well  also  to  insert,  as  we  have  done  in 
the  figure,  a  short  length  of  glass  tubing  not  far  from  the 
needle,  so  that  when  the  instrument  is  used  for  gas-replace- 
ment (p.  114)  the  entry  of  fluid  into  the  tubing  may  at  once 
be  detected,  should  this  occur.  The  fourth  limb  of  the  cross- 
piece,  to  which  in  Plate  XXXIII.  a  short  piece  of  rubber 
tubing  with  clamp  is  attached,  has  been  added  at  the  sugges- 
tion of  Dr.  L.  S.  T.  Burrell  to  facilitate  refilling  of  the  gas 
bottle  with  air,  should  this  be  necessitated  during  the  progress 
of  the  operation. 

For  the  initial  operation  and  for  the  first  few  reinflations 
the  patient  must  be  in  bed.  A  suitable  site  for  the  puncture 
is  to  be  found  in  the  lower  axillary  region,  as,  for  example, 
the  sixth  space  in  the  mid-axillary  line,  since  here,  as  we 
have  pointed  out  in  dealing  with  paracentesis  thoracis, 
the  parietes  are  thin  and  the  intercostal  spaces  roomy,  and 
adhesions  are  less  likely  to  be  present.  If,  however,  ad- 
hesions prevent  the  introduction  of  air,  attempts  must  be 
made  in  other  regions  in  the  lower  part  of  the  chest,  such 
as  the  eighth  or  ninth  space  below  the  angle  of  the  scapula, 
where  physical  signs  indicate  but  little  disease.     If  three  or 


PLATE  XXXIII 


Apparatus  for  performing  Artificial  Pneumothorax  devised  by  Dr.  Vere 
Pearson  and  Dr.  Lillingston  (Slightly  Modified). 

^°ral7cTntimil'r^.'-  Jj^^ '■?^'1'"S  "f 'l?^i"t^^-pleural  pressure,  the  manometer  scale  is  graduated  in 
a  simn^r^?:  ■•  ■  "'u  °'  ^u  "  ?•  'u^  T^'r  '"  '^^  •'"^'^  ^-^P^^^d  to  the  air  being  accompanied  bv 
a  smiilar  fall  or  rise  in  the  other  limb,  the  figures  give  the  pressure  in  cc.  of  water  ^ 


To  face  p.  720. 


TREATMENT   OF  PULMONARY  TUBERCULOSIS  Jll 

four  punctures  prove  fruitless,  owing  to  the  presence  of 
widespreading-  adhesions,  the  operation  must  be  abandoned. 
Professor  Saugman"  met  with  faihire  in  43  of  his  138  cases. 

The  selection  of  the  pneumothorax  needle  is  of  importance. 
At   first   a   pointed    needle    was    used,    but    with    this    there 
is    some    danger    of    wounding    the    lung,    with    the    pos- 
sibility   of    gas     embolism     when     the     air    is     introduced, 
and   there    can    be    no    doubt    that    an    instrument    such    as 
that  devised  by  Dr.  Riviere"^  is  better  for  the  initial  opera- 
tion.    This  consists  of  a  trocar  and  cannula,  the  latter  of 
1-8  millimetres  ('072  inch)  gauge,  with  a  side-opening  near  the 
tip,  and  with  a  sharpened  cutting  end.    The  trocar  and  cannula 
are  carefully  introduced  to  a  depth  of  about  f  centimetre, 
when  the  shoulder  of  the  cannula  will  have  passed  through 
the  skin.     The  trocar  is  then  withdrawn  and  the  tap  of  the 
needle  closed.     The  cannula  with  its  sharpened  circular  end 
is  slowly  pressed  onward  until  the  pleura  is  reached  and  the 
sudden    "  snap "    is    experienced,    which    indicates    that    the 
parietal  pleura  has  been  perforated.     This  will  be  confirmed 
by  the  sudden  appearance  in  the  manometer  of  a  negative 
pressure   of  some    10  centimetres   of  water,  and  a   definite 
respiratory   fluctuation    of    from    4   to    8    centimetres.     The 
depth  at  which  the  pleura  is  situated  will  naturally  vary  with 
the  thickness  of  the  parietes ;  in  thin  subjects  it  may  be  only 
I  centimetre  from  the  surface,  and  Professor  Saugman  has 
never  found  it  at  a  greater  depth  than  3  centimetres. 

When  it  is  thus  made  clear  that  the  needle  is  in  the  pleural 
cavity  air  may  be  introduced.  On  the  first  occasion  about 
400  c.c.  are  often  sufficient,  but  the  amount  must  depend  to 
some  extent  upon  the  size  of  the  chest  and  the  ease  with 
which  the  lung  collapses.  At  the  end  of  the  first  inflation  the 
intrapleural  pressure  should  still  be  slightly  negative.  When, 
however,  the  operation  is  done  to  check  haemoptysis,  1,000  c.c. 
should  at  once  be  introduced.  The  air  at  first  is  somewhat 
quickly  absorbed  from  the  pleura,  and  further  inflations  must 
be  made  at  intervals  of  a  fevv^  days,  later  at  intervals  of  a  week, 
then  a  fortnight,, and  at  last,  when  the  pneumothorax  is  well 
established,  at  intervals  of  four  to  eight  weeks  or  even  longer. 
The  amount  of  air  introduced  at  each  refill  is  gradually  in- 
creased, so  that  at  the  fourth  or  fifth  inflation,  when  the  lung 
is    completely    collapsed,    the    intrapleural    pressure    at    the 

46 


722  DISEASES   OF  THE  LUNGS   AND  PLEURA 

termination  of  the  operation  should  measure  about  +  5  centi- 
metres of  water.  The  object  of  the  treatment  is  to  obtain, 
without  undue  stretching  of  the  mediastinum  and  without  dis- 
comfort to  the  patient,  as  complete  a  collapse  of  the  lung  as 
possible,  so  that  when  examined  by  the  X-rays  it  may  be  seen 
lying  by  the  side  of  the  vertical  column.  The  dates  of 
further  refills,  and  the  quantity  of  gas  introduced,  should  be 
controlled  when  possible  by  noting  on  the  screen  whether 
the  lung  remains  collapsed  or  shows  a  tendency  to  re-expand. 
The  presence  of  bands  of  adhesions,  which  prevent  complete 
collapse  of  the  lung  and  militate  against  the  efficiency  of  the 
treatment,  are  also  brought  into  evidence  by  X-ray  examina- 
tion. For  the  reinflations  the  trocar  and  cannula  may  be  again 
used,  or,  if  desired,  a  pointed  needle,  such  as  that  devised  by 
Professor  Saugman,  since  the  needle  will  now  enter  a  cavity 
already  containing  air,  and  there  is  not,  therefore,  the  same  risk 
of  wounding  the  lung  as  at  the  first  operation.  The  needles 
should  be  kept  in  absolute  alcohol  and  dried  before  use  by 
passing  through  the  flame,  thus  rendering  them  aseptic  and 
insuring  that  the  lumen  is  free  from  fluid,  and  capable  at 
once  of  registering  the  intrapleural  pressure. 

The  performance  of  an  artificial  pneumothorax  is  not  en- 
tirely free  from  risk,  since  occasionally,  at  the  moment  of 
perforating  the  pleura,  the  patient  becomes  faint  and  the 
pulse  and  respiration  irregular,  and  in  a  few  cases  such  an 
attack  has  terminated  fatally,  death  being  attributed  to  reflex 
spasm  of  the  cardiac  or  cerebral  vessels.  To  this  condition 
the  terms  "pleural  reflex"  and  "pleural  shock"  have  been 
applied,  and  its  occurrence  has  been  noted  in  other  mani- 
pulations of  the  pleura,  notably  irrigation,  and  for  this 
reason  we  have  advised  against  this  procedure  save  in  very 
exceptional  circumstances  (p.  129).  Experimental  evidence 
suggests  that  the  danger  of  pleural  reflex  is  diminished  by 
proper  anaesthesia,  and  in  performing  artificial  pneumothorax 
it  is  well  always  to  give  a  sedative,  such  as  an  injection  of 
morphia  (gr.  ^)  or  omnopon  (gr.  ^)  half  an  hour  before  the 
initial  operation,  and  carefully  to  ancesthetise  the  site  of 
puncture  right  down  to  the  pleura  with  a  sterilised  2  per 
cent,  solution  of  novocaine  in  normal  saline.  At  the  refill 
the  sedative  is  not  usually  needed,  but  the  local  anaesthetic 
should  be  employed. 


TREATMENT   OF   PULMONARY  TUBERCULOSIS  723 

The  danger  of  gas  embolism  from  the  introduction  of  air 
into  a  vessel  of  the  lung  has  with  improving  technique  been 
largely  eliminated,  and  the  accident  should  be  of  the  greatest 
rarity/  provided  that  care  be  taken  never  to  introduce  the 
air  until  the  negative  pressure  and  the  respiratory  excursion, 
as  registered  by  the  manometer,  prove  that  the  needle  is  free 
in  the  pleural  cavity. 

Duration  of  Treatment. — How  long  the  treatment  should 
continue  and  the  compression  of  the  lung  be  maintained  is 
a  matter  in  regard  to  which  there  is  some  difference  of 
opinion,  and  there  is  at  the  present  time  a  tendency  to 
lengthen  the  duration  of  treatment.  It  is  generally  felt,  how- 
ever, that  eighteen  months  to  two  years  is  a  wise  minimum, 
and  that  in  more  serious  and  advanced  cases  this  may  be 
extended  to  three  or  even  four  years,  inflations  being  given 
at  the  later  stages  at  intervals  of  six  to  eight  weeks  or  even 
longer.  During  the  period  of  compression  the  lung  under- 
goes some  degree  of  fibrosis,  and  it  is  possible  that  it  may 
not  fully  expand  when  the  treatment  is  discontinued,  so  that 
the  chest  falls  in  to  some  extent. 

Complications. — During  the  course  of  treatment  two  com- 
plications may  be  met  with  which  we  must  now  consider. 
These  are  pleurisy  and  perforation  of  the  lung. 

I.  Pleurisy. — This  is  a  common  complication  of  artificial 
pneumothorax,  and  occurs,  it  is  estimated,  in  nearly  half  the 
cases,  especially  those  in  which  the  disease  is  acute  in  char- 
acter or  advanced  in  degree.  It  is  usually  attended  with  effu- 
sion, which  is  as  a  rule  serous  in  character,  sterile  on  culture, 
and  containing  tubercle  bacilli.  Later  the  fluid  sometimes 
becomes  purulent. 

The  complication  occurs  most  commonly  within  the  first 
three  months;  in  other  cases  at  some  later  period  during  the 
course  of  treatment,  possibly  not  until  the  third  or  fourth 
year.  The  symptoms  are  sometimes  very  shght,  but  in  other 
cases  the  onset  is  sudden,  with  pyrexia  and  pain  in  the  side, 
the  temperature  remaining  raised  for  two  or  three  weeks  or 
more,  and  thea  falling  gradually  to  normal,  as  in  the  case  of  a 
simple  pleurisy  with  effusion.  The  rapid  effusion  of  fluid 
in  such  cases  may  raise  the  intrapleural  pressure  and  em- 
barrass the  respiration,  and  thus  necessitate  the  withdrawal 
of  some  of  the  air;  but  in  our  experience  the  occurrence  of 


724  DISEASES  OF  THE  LUNGS   AND   PLEURAE 

effusion,  when  the  febrile  stage  has  passed,  is  often  helpful 
rather  than  the  reverse  to  the  patient,  by  tending  to  keep  the 
lung  collapsed  and  thus  allowing  of  refills  at  longer  intervals. 

2.  Perforation  or  Rupture  of  the  Lung  is  fortunately  an 
event  of  rare  occurrence,  though  we  have  seen  at  least  one 
instance,  and  several  are  recorded  by  Dr.  Sachs,®  Drs. 
Marshall  and  Craighead^  and  other  observers.^  It  is  apt  to 
occur  where  adhesions  prevent  more  than  a  partial  pneumo- 
thorax, and  the  lung  is  thus  stretched  and  unprotected.  It 
is  perhaps  surprising  that  the  accident  should  not  occur 
more  often  in  such  cases,  when  it  is  remembered  that  the 
pleural  surfaces  are  deliberately  separated  by  the  air  intro- 
duced, and  thus  the  formation  of  adhesions  over  patches  of 
advancing  disease,  which  so  often  prevent  pneumothorax,  is 
no  longer  possible.  The  accident  occurs  sometimes  in  cases 
of  active  disease;  in  others  the  patient  has  been  doing  well 
and  leading  perhaps  too  active  a  life,  when  the  stretched 
portion  of  lung  gives  way.  The  onset  of  the  complication 
is  marked  by  sudden  pain  in  the  side  and  high  fever;  and 
death  often  quickly  follows  from  septic  pyopneumothorax. 

The  following  is  a  brief  note  of  the  case  which  came  under 
our  own  observation  : 

B.  E.  P.,  aged  twenty-four,  shop  assistant,  was  admitted  into  the 
Brompton  Hospital  on  June  19,  1912,  under  the  care  of  Dr.  Hartley, 
suffering  from  pulmonary  tuberculosis,  of  a  year's  duration,  affecting 
the  whole  of  the  left  lung  and  the  upper  part  of  the  right.  Tubercle 
bacilli  were  present  in  the  sputum. 

The  case  proved  febrile,  the  temperature  being  irregularly  raised, 
generally  to  100°  and  sometimes  higher.  After  some  four  months' 
treatment  it  became  clear  that  the  patient  was  not  making  progress, 
and  an  artificial  pneumothorax  was  decided  upon.  This  was  per- 
formed by  Dr.  Hartley  on  November  5,  the  left  pleura  being  punc- 
tured in  the  eighth  space  in  the  line  of  the  angle  of  the  scapula,  and 
200  c.c.  of  nitrogen,  which  gas  we  were  at  the  time  using,  introduced. 
On  November  7,  11,  and  19,  reinflations  were  given,  200,  375,  and 
300  c.c.  of  nitrogen  being  respectively  introduced.  The  highest 
pleural  pressure  reached  was  +2;  on  the  last  occasion  at  the  end 
of  the  inflation  it  was  — 1|.  During  this  time  the  patient  improved 
somewhat  and  the  temperature  was  rather  lower.  The  X-ray  report 
by  Dr.  Melville  showed  a  partial  pneumothorax,  the  lung  being 
adherent  above  the  third  rib,  and  in  the  region  of  the  diaphragm. 

On  November  20  the  patient  experienced  a  sudden  pain  and  feeling 
of  "  tightness  "  in  the  side,  and  the  temperature  rose.  Two  days 
later   the  pulse  was    144   arid   the   temperature    103°.     The   physical 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  725 

signs  of  a  partial  pneumothorax  persisted,  as  also  the  pyrexia,  and 
the  patient  gradually  became  weaker.  On  December  18  she  began 
to  cough  up  purulent  expectoration,  amounting  on  one  day  to  5xx., 
and  this  continued  until  death  on  December  23.  Rupture  of  the 
lung  into  the  cavity  of  the  artificial  pneumothorax,  with  pyopneumo- 
thorax and  expectoration  of  the  pus,  was  diagnosed,  but  the  patient 
was  too  ill  for  surgical  treatment. 

At  the  autopsy  a  partial  left  pneumothorax  was  found,  the  lung 
being  adherent  over  its  upper  third.  A  small  perforation  of  the 
visceral  pleura  leading  into  the  lung  was  discovered  at  the  apex  of 
the  left  lower  lobe,  and  the  pleura  contained  4  ounces  of  pus.  Two 
or  three  cavities,  the  size  of  a  walnut,  were  present  in  the  left  upper 
lobe,  with  more  recent  infiltration  of  the  lower  lobe,  and  scattered 
areas  of  disease  throughout  the  whole  of  the  right  lung. 

Cases  Suitable  for  Treatment. — From  what  we  have  said  in 
the  preceding  paragraphs  it  is  evident  that  treatment  by  arti- 
ficial pneumothorax  is  not  entirely  devoid  of  risk,  though 
modern  methods  of  procedure  have  reduced  this  most 
materially.  This  being  so,  it  must  be  agreed  that  no  case 
should  be  submitted  to  treatment  until  a  full  trial  has  been 
given  to  more  ordinary  methods.  If,  however,  the  patient 
fails  to  respond  to  rest,  sanatorium  treatment,  and  medicinal 
remedies,  then  the  question  of  an  artificial  pneumothorax 
should  be  considered,  nor  should  this  consideration  be  unduly 
delayed.  The  initial  operation  and  early  refills  are  often  best 
carried  out  at  a  sanatorium,  since  here  the  patient  has  the 
hygienic  and  other  advantages  associated  with  such  an 
institution. 

The  cases  for  which  the  method  is  especially  suitable  are 
those  in  mhich  the  disease  affects  chiefly  one  lung,  so  that 
when  this  is  collapsed  the  diseased  areas  are  at  once  brought 
under  the  influence  of  the  treatment.  In  such  patients,  when 
other  methods  have  failed,  an  artificial  pneumothorax  some- 
times brings  the  temperature  down  in  an  almost  dramatic 
manner,  with  a  corresponding  improvement  in  the  patient's 
symptoms,  although  in  our  experience  the  fall  is  usually  more 
gradual,  a  normal  temperature  being  reached  only  after 
several  inflations. 

We  have  also  seen  benefit  from  the  treatment  in  patients 
with  chiefly  unilateral  disease  of  a  less  acute  type  than  the 
above,  but  in  whom  any  attempt  to  increase  the  exercise  or 
work  allowed  leads   to  a   set-back,   whether  indicated  by  a 


726  DISEASES   OF  THE  LUNGS   AND  PLEURAE 

rise  of  temperature,  a  rapid  pulse,  or  increased  cough  and 
sputum. 

The  method  is  of  great  value  also  in  the  case  of  patients, 
generally  with  somewhat  advanced  disease,  who  are  the  sub- 
jects of  repeated  haemoptysis,  pointing  to  the  presence  of  a 
pulmonary  aneurism.  In  these  cases  the  performance  of  an 
artificial  pneumothorax  will  check  the  haemorrhage,  which 
may  not  recur,  provided  that  the  compression  is  duly  main- 
tained. 

In  cases  of  acute  pneumonic  phthisis  the  method  holds  out 
less  hope,  since  here  we  are  dealing  with  extensive  and 
massive  areas  of  caseation,  yet  in  one  such  case  we  have 
known  a  gratifying  result.  We  have  also  under  observation 
at  the  present  time  a  case  of  rapidly  extending  phthisis,  not 
confined  to  one  lung,  with  continuous  high  temperature,  and 
in  which  the  outlook  appeared  "  hopeless,"  yet  here  compres- 
sion of  the  most  affected  lung,  though  soon  complicated  by 
acute  pleurisy  with  effusion,  has  led  to  great  improvement 
in  the  patient's  condition  and  a  gradual  fall  of  temperature 
to  normal.  Two  somewhat  similar  instances  are  recorded 
by  Professor  Saugman.*  Such  cases  are  no  doubt  excep- 
tional, and  we  would  emphasise  again  that  it  is  for  patients 
in  whom  the  disease  is  chiefly  conflned  to  one  lung  or  those 
whose  life  is  endangered  by  repeated  and  uncontrollable 
hcemoptysis  that  the  treatment  is  especially  suitable.  Early 
laryngeal  disease  is  no  bar  to  the  treatment,  but  it  should  not 
be  advised  in  the  case  of  patients  with  intestinal  tuberculosis, 
weakened  myocardium,  or  other  serious  complications. 

Results  of  Treatment. — We  have  indicated  that  in  suitable 
cases  the  immediate  results  obtained  by  the  induction  of  an 
artificial  pneumothorax  are  sometimes  very  satisfacory,  the 
patient  improving-  greatly  during  the  continuance  of  the 
treatment,  being  enabled  to  lead  an  active  life,  and  not  infre- 
quently losing  his  cough  and  phlegm,  while  tubercle  bacilli 
disappear  from  the  sputum. 

With  the  cessation  of  the  treatment  these  good  results 
not  seldom  persist,  the  lung  expanding  to  a  greater  or  less 
degree,  but  the  permanence  or  otherwise  of  the  results  will 
depend  largely  on  the  after-care.  The  patient  must  not 
regard  himself  as  cured.  Tubercle  bacilH  are  still  present  in 
the  lesions,  and  the  disease  will  break  out  afresh  if  he  be  not 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  727 

content  to  carry  out,  though  in  a  modified  manner,  the  mode 
of  life  which  he  has  learnt  at  the  sanatorium. 

In  other  cases,  though  the  immediate  results  may  be  encour- 
aging, the  disease  in  the  other  lung  gradually  extends  and  the 
patient  finally  succumbs.  In  others,  again,  the  treatment 
fails,  because  the  presence  of  adhesions  prevents  the  due 
compression  of  the  lung. 

It  will  be  interesting,  in  conclusion,  to  quote  the  results 
which  have  been  obtained  at  the  Berks  and  Bucks  Sanatorium 
by  Dr.  Esther  Carling^'  after  eight  years'  experience  of  the 
method.  The  figures  given  below  are  brought  up  to  date 
(June  30,  1920),  Dr.  Cading  having  courteously  supplied 
us  with  the  additional  data,  and  verified  the  figures.  The 
patients  treated  belonged  to  the  working  classes,  and  were 
all  advanced  or  acute  cases,  with  more  or  less  unilateral 
disease.  Ah  had  failed  to  respond  to  ordinary  sanatorium 
treatment,  and  in  all  "the  outlook  was  thoroughly  bad." 

Of  the  54  cases  submitted  to  the  treatment,  in  12  it  was  not 
possible  to  effect  a  pneumothorax,  and  of  these  12  patients 
10  are  now  dead. 

Of  the  42  in  whom  compression  of  the  lung  was  effected, 
23  are  dead.  In  more  detail  the  results  in  these  cases  are  as 
follows : 

(a)  In  12  the  treatment  failed  and  the  disease  progressed 
unchecked,  until  the  death  of  the  patient.  This 
group,  it  should  be  noticed,  included  all  the  cases 
in  which  the  lung  was  incompletely  collapsed. 

{h)  In  8  temporary  improvement  was  manifested.  Of 
these  8,  2  are  dead,  and  the  remaining  6  are  at  home, 
but  unable  to  work. 

{c)  In  22  marked  improvement  occurred.  Nine  of  these 
patients  have,  however,  since  died.  The  remaining 
73  have  returned  to  their  old  occupation,  or  to  a 
moderately  active  and  useful  life.  Five  of  these  13 
are  continuing  treatment  by  periodical  return  to  the 
sanatorium  or  to  the  Tuberculosis  Officer  for  reinfla- 
tiqns. 

Considering  the  type  of  case  treated  and  the  difficuhies  of 
efficient  after-care  in  view  of  the  class  of  patients  dealt 
with,    so    marked    and    lasting    an    improvement    in    13    out 


728  DISEASES   OF   THE  LUNGS   AND   PLEtJR.^: 

of  42  patients  must  be  regarded  as  a  hopeful  and  encouraging 
achievement. 

Surgical  InterYention. 

We  have  now  to  ask  ourselves  whether  it  is  possible  to 
assist  in  any  way  the  30  per  cent,  of  cases  which,  though  suit- 
able on  medical  grounds  for  treatment  by  artificial  pneumo- 
thorax, are  yet  unable  to  benefit  from  it  owing  to  the  presence 
of  widespread  adhesions. 

Thoracoplasty. — For  a  few  of  them  some  form  of  extra- 
pleural thoracoplasty  may  be  considered,  whereby  varying 
lengths  of  the  ribs  (but  not  the  entire  ribs)  from  the  first  to 
the  tenth  or  eleventh  are  removed  on  one  side.  The  opera- 
tion, which  is  infinitely  more  grave  than  that  of  artificial 
pneumothorax,  is  best  done  in  two  stages,  so  as  to  diminish 
the  shock,  and  should  be  performed  when  possible  under  local 
anaesthesia,  especial  care  being  taken  to  anaesthetise  the 
various  intercostal  nerves.  With  the  avoidance  of  a  general 
anaesthetic  the  risk  of  aspirating  septic  secretions  into  the 
healthy  lung  when  the  diseased  lung  collapses  is  greatly 
diminished,  and  the  danger  of  the  operation  lessened. 

We  have  known  one  or  two  notable  examples  of  the  suc- 
cessful performance  of  the  operation,  with  great  and  lasting 
benefit  to  the  patient;  but  the  operation  is  an  exhausting  one, 
and  even  in  skilled  hands  has  a  mortality  of  about  10  per 
cent.  It  should  never,  therefore,  be  contemplated  until  other 
methods  of  treatment  have  failed  and  until  an  artificial 
pneumothorax  has  proved  impossible. 

Professor  Bull'  of  Christiania  has  recently  pubHshed  a 
record  of  37  cases,  of  which  4  died  as  a  result  of  the  opera- 
tion, and  1 1  are  stated  to  have  achieved  a  "  curative  result," 
by  which  is  meant  that  the  patients  were  at  work,  afebrile, 
and  with  the  sputum  no  longer  containing  tubercle  bacilli. 

Professor  Saugman'"  also  reports  the  result  of  40  cases 
treated  at  the  Vejlefjord  Sanatorium,  22  of  which  were  oper- 
ated upon  by  himself.  Of  these  40  patients,  4  died  as  a  result 
of  the  operation,  12  are  still  in  the  sanatorium,  and  13  are 
able  to  work,  though  of  these  6  are  capable  of  Hght  work 
only.  In  regard  to  the  type  of  case  operated  upon,  29  of 
the  patients  showed  some  degree  of  fever,  but  it  is  to  be 
noted  that  the  cases  chosen  for  operation  were  for  the  most 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  729 

part  of  the  chronic  type,  with  disease  chiefly  one-sided.  In- 
deed, Professor  Saugman  expressly  states  that  acute  cases 
are  not  specially  suitable,  as  so  often  active  and  progressive 
tuberculosis  has  already  commenced  in  the  other  lung,  which 
unilateral  collapse  will  not  check. 

Rib  Mobilisation. — Another  operation  which  diminishes  the 
volume  of  the  chest  and  allows  considerable  collapse  of  the 
lung  is  that  introduced  by  Wilms,  and  known  as  "  rib 
mobilisation."  We  have  referred  to  this  when  considering 
the  treatment  of  bronchiectasis  (p.  220),  and  need  only  add 
that  it  is  an  operation  which,  while  having  the  same  object 
and  effect  as  thoracoplasty,  is  somewhat  less  hazardous, 
though  by  no  means  free  from  danger.  It  should  therefore 
be  considered  when  serious  surgical  intervention  is  contem- 
plated, though  no  doubt  the  particular  experience  of  the 
surgeon  will  be  the  important  factor  in  deciding  upon  the 
exact  method  of  operation. 

In  our  opinion  these  drastic  surgical  procedures  should 
only  be  considered  in  cases  of  pulmonary  tuberculosis  where 
all  other  methods,  including  artificial  pneumothorax,  have 
failed,  and  where  the  disease,  if  febrile,  is  not  of  a  very  acute 
type  and  chiefly  restricted  to  one  lung,  or,  if  more  chronic, 
keeps  the  patient  a  more  or  less  permanent  invalid.  If  the 
patient  appreciates  the  deformity  of  chest  which  will  result 
and  the  danger  of  the  operation,  and  decides  to  take  the  risk, 
then  the  operation  may  be  sanctioned,  provided  the  heart  and 
other  organs  are  healthy  and  the  general  vitality  of  the 
patient  sufficiently  good.  In  our  experience  this  favourable 
combination  of  circumstances  is  not  often  met  with. 

Opening  and  Drainage  of  Tuberculous  Cavities. — The  sur- 
gical procedures  which  we  have  found  of  value  when 
dealing  with  abscess  and  gangrene  of  the  lung  (p.  360)  are 
seldom  profitable  in  the  case  of  tuberculous  cavities.  Such 
cavities  are  rarely  single,  and  are,  moreover,  usually  situated 
at  the  apex  or  upper  part  of  the  lung,  so  that  drainage  per 
vias  naturales  is  fairly  well  maintained,  and  the  chief  reason 
for  interference  is  in  the  majority  of  cases  not  present. 

Cases  from,  time  to  time,  however,  do  present  themselves 
in  which  the  extent  of  excavation,  the  superficial  position  of 
the  cavity,  and  the  large  amount  of  secretion,  with  irritating 
and   exhausting   cough,   suggest   external    drainage,    and   in 


730  DISEASES   OF   THE  LUNGS   AND   PLEUR.E 

some  instances  an  attempt  is  made  by  nature  to  find  an 
external  vent  by  perforation  of  the  chest  wall.  If  in  such 
cases  all  other  means  have  failed,  and  the  patient's  pitiable 
condition  demands  interference,  opening  and  drainage  may 
be  considered. 

An  interesting  case  of  this  kind,  under  the  care  of  Dr.  John 
Hastings  and  Mr.  Robert  Storks,"  was  operated  upon  as 
long  ago  as  1844.  The  cavity,  a  large  left  apical  one,  was 
incised  through  the  second  intercostal  space,  and  a  drainage- 
tube  inserted,  with  immediate  relief  to  cough  and  expectora- 
tion. Since  then  other  selected  cases  have  been  treated  in  a 
similar  way,^^  and  not  infrequently  with  some  amelioration  of 
symptoms.  But  the  operation  cannot  be  looked  upon  as 
more  than  a  palliative,  and  one  which  may  alleviate  the 
patient's  most  distressing  symptoms,  the  harassing  cough 
and  abundant  expectoration.  Under  the  modern  hygienic 
methods  of  treatment  such  large  secreting  cavities  are  not 
common,  and  intervention  is  now  rarely  called  for. 


REFERENCES 

^  {a)  Pneumothorax    Treatment    of    Pulmonary    Tuberculosis,    by    Clive 
Riviere,  M.D.,  F.R.C.P.     London,  1917.     See  also — 
(6)   Tubercle,  1919,  vol.  i.,  p.  114. 

^  "  Artificial  Pneumothorax  :  Fundamental  Defects  in  the  Accepted 
Technique  of  inducing  Pneumothorax  and  how  to  Remedy  Them,"  by  W. 
Parry  Morgan,  M.A.,  M.B.,  B.Sc,  the  Lancet,  1914,  vol.  ii.,  p.  90. 

^  "  Apparatus  for  the  Production  of  Artificial  Pneumothorax,"  by 
S.  Vere  Pearson,  M.D.,  British  Medical  Journal,  1913,  vol.  ii.,  p.  1098. 

^  "  On  the  Results  of  the  Pneumothorax  Treatment  of  Phthisis,"  by 
Professor  Chr.  Saugman,  Seventeenth  International  Congress  of  Medicine. 
London,  1913.     Section  of  Medicine.     Part  ii.,  pp.  463  and  477. 

^  "  The  Dangers  of  Artificial  Pneumothorax,"  by  B.  Slivehnan,  M.D.,. 
the  New  York  Medical  Journal,  1919,  vol.  cix.,  p.  187. 

^  "  Artificial  Pneumothorax  in  the  Treatment  of  Pulmonary  Tubercu- 
losis :  Results  obtained  by  Twenty-four  American  Observers,"  by  Theodore 
B.  Sachs,  M.D.,  the  Journal  of  the  American  Medical  Association, 
191 5,  vol.  Ixv.,  p.  1 861. 

'  "  Spontaneous  Pneumothorax  during  the  Course  of  Induced  Pneumo- 
thorax," by  M.  I.  Marshall  and  J.  W.  Craighead,  American  Review  of 
Tuberculosis,  1917-1918,  vol.  i.,  p.  540. 

*  "  The  Value  of  Artificial  Pneumothorax  :  Impressions  after  Eight 
Years  and  Fifty-four  Cases,"  by  Esther  Carling,  M.D.,  Tubercle,  1920. 
vol.   i.,  p.  411. 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  73 1 

'  "  Videre  erfaringer  om  behardlingen  av  Lunge-tuberkulose  med  extra- 
pleural thorako-plastik,"  by  Peter  Bull  (Christiania),  Norsk.  Mag.  for 
Laegevi-denskaben,  1919,  80,  p.  1105.     (See  Tubercle,  1920,  vol.  i.,  p.  330.) 

"  "  Thoracoplasty  in  the  Treatment  of  Pulmonary  Tuberculosis,"  by 
Professor  Chr.  Saugman,  Tubercle,  1920,  vol.  i.,  p.  305. 

"  "  A  Case  of  Tuberculous  Excavation  of  the  Left  Lung  treated  by 
Perforation  of  the  Cavity  through  the  Walls  of  the  Chest,"  by  John 
Hastings,  M.D.,  and  Robert  Storks,  Esq.,  Surgeon,  the  London  Medical 
Gazette,  December  20,    1844. 

'^  The  Surgery  of  the  Chest,  by  Stephen  Paget,  M.A.,  F.R.C.S., 
pp.  331  and  446.     Bristol  and  London,  1896. 


CHAPTER   LII 

TREATMENT  OF   PULMONARY  TV BERCULOSIS— {Concluded) 

Epitome. 

Tt  may  be  useful  now  to  epitomise  what  we  have  said  in 
regard  to  the  treatment  of  pulmonary  tuberculosis. 

We  have  shown,  in  the  first  place,  what  hygienic  and 
climatic  measures  may  do,  and  it  may  be  said  that  the  limit  of 
their  efficacy  has  now  been  fairly  ascertained. 

We  have  further  indicated  what  can  be  effected  by  the  use 
of  vaccines,  sera,  etc.,  and  although  these  remedies  have  on 
the  whole  proved  very  disappointing,  they  have  yet  led  us 
better  to  appreciate  the  mechanism  of  immunisation,  and 
have  enabled  us  to  perceive  that  it  is  through  the  absorption 
of  what  may  be  called  autogenous  toxines,  derived  from 
lesions  present  in  tuberculosis,  that  immunity  is  largely  de- 
rived; and  that  duly  regulated  methods  of  hygienic  exercises 
are  the  means  of  restraining  such  absorption  within  such 
limits  as  may  bring  about  the  end  desired — immunity  from 
further  attack — and  thus  allow  existing  lesions  to  heal. 

We  have  traversed  the  field  of  drug  treatment,  and  have  here, 
too,  experienced  many  disappointmicnts  in  the  failure,  time 
after  time,  of  reputed  specific  medication.  It  must  be  noted, 
however,  that  amidst  the  debris  of  discarded  remedies  we 
may  yet  find  encouragement  for  present  hope  and  further 
research.  For  the  treatment  of  the  symptoms  of  the  disease, 
cough,  wasting,  exhaustion,  and  special  symptoms  that  may 
arise,  we  have  many  appropriate  remedies.  One  class  of 
drugs,  also,  seems  to  us  to  give  promise  of  continued  useful- 
ness— namely,  the  antiseptic  group  of  remedies,  especially  the 
creosote  group,  and  perhaps  also  the  derivatives  of  arsenic, 
as  tending  to  check  the  activity  of,  if  not  to  destroy,  the 
Bacillus  tuberculosis  and  its   associated   organisms,  and   to  • 

732 


TREATMENT  OF  PULMONARY  TUBERCULOSIS  733 

render  them  more  amenable  to  phagocytic  and  other 
attack. 

Finally,  we  have  seen  that  in  artificial  pneumothorax, 
whereby  the  lung  is  collapsed  and  placed  at  rest,  we  possess 
a  method  of  treatment  which  is  valuable  in  a  certain  propor- 
tion of  cases  when  other  methods  have  failed. 

We  may  claim,  therefore,  that,  since  our  last  edition  was 
published,  progress  in  treatment  has  been  made,  and  we  must 
hope  that  the  day  is  not  far  distant  when  research  will  place 
in  our  hands  a  specific  means,  whether  medicinal  or  other, 
wherewith  to  combat  the  disease.  This  must  be  the  aim  of 
investigators,  and  we  cannot  believe  that  the  hope  is 
chimerical. 


CHAPTER  LIII 

ON  ABSCESS  IN  THE  MEDIASTINUM 

Suppurative  mediastinitis  is  a  somewhat  rare  disease,  and  is 
probably  never  of  primary  origin.  The  causes  of  abscess  in 
this  situation  may  be  thus  enumerated : 

1.  Gunshot  wounds.^ 

2.  Injury  to  the  sternum. 

3.  Post-st€rnal  syphilitic  node. 

4.  Perforation  of  the  oesophagus  or  injury  from  the  impac- 
tion or  penetration  of  foreign  bodies,  or  malignant  growth. 

5.  Septic  causes,  whether  pyaemic  in  nature,  or  associated 
with  enteric  fever,  or  arising  by  extension  from  pneumonia, 
gangrene  of  the  lung,  streptothrix  disease  of  the  lung  and 
pleura,  or  tracheotomy. 

6.  Glandular  suppuration,  most  commonly  in  association 
with  tuberculous  disease,  but  sometimes  occurring  after 
whooping-cough. 

7.  Suppurating  hydatid. 

8.  Caries  of  the  spine. 

Symptoms. — The  presence  of  a  wound,  the  history  of  a 
blow  or  of  some  astiological  factor  of  the  kind  alluded  to  in 
the  above  list,  and  the  discovery  of  symptoms  and  signs 
pointing  to  mediastinal  inflammation,  are  the  elements  of 
diagnosis  in  this  often  obscure  disease.  Pain  and  tenderness, 
pressure  signs  only  very  moderate  in  degree,  and  pyrexia, 
are  the  symptoms  most  worthy  of  notice.  The  pain  is  seated 
behind  the  sternum  or  between  the  shoulders,  and  radiates 
from  these  regions.  Paroxysmal  cough  of  the  laryngeal  type, 
a  certain  amount  of  obstruction  to  venous  return,  and  some 
pain  or  difficulty  in  swallowing,  are  the  pressure  phenomena 
which  may  be  observed  in  cases  of  abscess  of  considerable 
size.  The  pyrexia  assumes  the  hectic  type,  and  is  attended 
with  rigors  and  sweatings. 

734 


ON  ABSCESS   IN  THE  MEDIASTINUM  735 

In  abscess  of  the  anterior  mediastinum  a  certain  degree  of 
fulness  over  the  superior  sternal  region  may  be  noticed  on 
inspection,  and  sometimes  there  is  also  a  red  blush  over  the  sur- 
face, and  a  slight  cedema  masking  the  outlines  of  the  carti- 
lages and  spaces.  Some  obscure  impulse  may  be  communicated 
from  the  aorta,  and,  in  cases  in  which  there  is  a  large  collec- 
tion of  pus  behind  the  sternum,  this  impulse  may  closely 
simulate  that  of  aneurism.  There  is  dulness  on  percussion 
over  the  region  of  pain  and  swelling,  with  unduly  conducted 
tracheal  breath-sound.  In  cases  in  which  the  aortic  sounds 
and  impulse  are  conducted,  it  is  important  to  make  several 
examinations  at  times  when  the  patient  is  at  rest  and  free 
from  cardiac  excitement. 

In  posterior  abscess  there  is  often  prominence  and  tender- 
ness over  one  or  two  of  the  dorsal  spinous  processes.  The 
percussion  and  auscultation  signs  are  very  obscure,  so  that 
the  frequent  association  of  spinal  caries,  with  its  characteristic 
external  signs,  is  of  much  importance  in  diagnosis.  X-ray 
examination  may  be  of  assistance  by  demonstrating  vertebral 
disease,  and  defining  the  outline  of  the  abscess. 

If  left  alone,  the  abscess  may  point  externally  or  rupture  into 
the  pleura,  pericardium,  lung  or  bronchus.  In  posterior  cases 
it  sometimes  burrows  along  the  vessels  between  the  pillars 
of  the  diaphragm,  and  finally  points  in  the  iliac  or  femoral 
region.  Most  commonly  anterior  mediastinal  abscesses  either 
point  externally  or  burst  into  a  bronchus.  Two  cases  which 
simulated  abscess  in  the  mediastinum,  but  which  proved  to  be 
an  aneurism  and  new  growth  respectively,  will  be  found  re- 
corded in  the  succeeding  chapter. 

Treatment. — In  the  earlier  stages  fomentations  should  be 
employed,  especially  in  those  cases  in  which  there  is  any 
external  tenderness.  In  cases  connected  with  caries  of  the 
spine  the  appropriate  treatment  for  that  affection  must  be 
adopted.  Complete  rest  is  in  all  cases  necessary.  The  patient 
requires  to  be  well  supported  by  general  treatment,  and 
quinine  may  be  administered  for  the  control  of  hectic. 

When  the  abscess  is  within  reach  of  surgical  treatment  it 
should  be  evacuated.  Cases,  however,  in  which  a  communi- 
cation with  a  bronchus  has  taken  place  should  not  be  inter- 
fered with  hastily,  as  the  abscess  may  thus  become  completely 
evacuated  and  heal  spontaneously. 


736  DISEASES   OF  THE  LUNGS   AND  PLEURA 

Chronic  mediastinitis  and  indurative  mediastino-pericarditis 
require  but  little  notice  in  this  work,  since  they  fall  rather  into 
the  domain  of  cardiac  diseases.  The  main  symptoms,  those 
of  gradual  heart  failure,  are  chiefly  due  to  thfe  adherent  peri- 
cardium which  is  so  frequently  present,  although  the  picture 
is  sometimes  complicated  by  obstruction  of  the  great  venous 
trunks,  owing  to  the  cicatricial  changes  in  the  fibrous  tissue 
in  which  they  are  embedded. 

REFERENCE. 

'  For  examples  occurring  in  the  recent  war  see  British  Medical  Journal, 
1916,  vol.  ii,,  Epit.,  Nos.  39  and  47. 


CHAPTER  LIV 

INTRATHORACIC  TUMOURS 

Tumours  within  the  chest  may  commence  in  the  mediastinum 
and  thence  invade  the  lungs,  or  originate  in  the  lungs  and 
spread  secondarily  to  the  mediastinum.  We  shall,  accord- 
ingly, consider  the  subject  under  the  two  headings :  (i) 
mediastinal  tumours,  (2)  tumours  of  the  lung — according  as 
the  disease  commences  in  one  or  other  situation. 

Tumours  of  the  Mediastinum. 

Various  growths,  both  innocent  and  malignant,  may  be  met 
with  in  the  mediastinum.  Of  these  the  great  majority  are 
malignant  in  nature.  Thus,  Hare,^  out  of  520  published  cases 
which  he  collected  from  1830  onwards,  found  only  7  examples 
of  fibroma,  11  of  dermoid  cyst,  8  of  hydatid  cyst  (in  most  of 
which  the  mediastinal  origin  was  doubtful),  3  of  lipoma,  3  of 
enchondroma;  and  even  these  figures  indicate,  probably,  too 
high  a  percentage,  the  uncommon  cases  having  naturally 
found  their  way  more  readily  into  literature. 

Of  mahgnant  tumours,  the  older  statistics  of  Hare^  and 
Wilson  Fox^  suggested  carcinoma  as  the  more  frequent 
cause,  but  they  were  based  largely  upon  cases  of  early  date, 
when  exact  methods  of  examination  were  not  at  hand.  Modern 
observations  show  that  the  new  growth  met  with  in  the 
mediastinum  is  commonly  sarcomatous  in  nature,  and  for  the 
most  part  lympho-sarcomatous  in  type'';  and  this  agrees  with 
our  own  experience.*  It  is  upon  this  form,  therefore,  the 
usual  variety  of  mediastinal  tumour,  that  our  description  of 
the  disease  will  be  based.  To  the  simple  tumours  we  do  not 
propose  to  refer  further.  Apart  from  dermoid  and  hydatid 
cysts,  which  are  described  elsewhere  in  this  work,  these 
tumours,  whether  of  the  lung  or  mediastinum,  are  extremely 
rare,  and  only  from  their  slow  growth  and  less  severe  symp- 

737  47 


738  DISEASES   OF  THE  LUNGS  AND  PLEURA 

toms  can  they  be  distinguished  from  those  of  more  malignant 
character. 

Malignant  growth  may  commence  in  various  structures  of 
the  mediastinum.  The  usual  seat  of  origin  of  sarcoma  is  in 
the  lymph  glands,  either  in  those  situated  anteriorly  in  the 
upper  part  of  the  mediastinum  (the  superior  mediastinum  of 
anatomists),  or  posteriorly  in  the  bronchial  glands,  or,  more 
rarely,  in  the  true  posterior  mediastinal  glands.  In  a  certain 
proportion  of  cases  the  growth  originates  in  the  remains  of 
the  thymus  gland,  and  occasionally  it  commences  in  the 
periosteum  of  the  vertebrae,  or  in  the  general  connective 
tissue.  When  arising-  in  the  glands,  the  growth,  having  once 
broken  through  the  capsule,  tends  rapidly  to  infiltrate  the 
neighbouring  parts,  involving  the  pericardium  and  extending 
along  the  vessels  and  bronchi  towards  the  root  of  the  lung. 
Thence  in  the  majority  of  cases  it  invades  that  organ  (more 
commonly  the  right  lung),  spreading  into  its  substance  along 
the  course  of  the  bronchi,  and  eventually  forming  a  large 
pinkish-white  and  fairly  firm  mass,  often  the  size  of  a  cricket- 
ball  or  even  a  child's  head,  which  much  distorts  the  natural 
shape  of  the  parts.  The  appearance  of  the  growth,  with  its 
radiating,  bulbous  prolongations,  is  illustrated  in  Plate 
XXXIV. 

Carcinoma  of  the  mediastinum  is  of  rare  occurrence.  It 
sometimes  occurs  as  an  invasion  from  neighbouring  parts, 
especially  the  oesophagus,  or  it  may  be  secondary  to  growth  in 
other  organs,  such  as  the  stomach  and  liver.  The  mediasti- 
num having  become  involved,  the  lung  may  be  invaded  later, 
as  in  the  case  of  sarcoma. 

Sarcomata  of  the  mediastinum  may  occur  at  any  period  of 
Hfe,  from  early  childhood  up  to  old  age,  but  between  the  ages 
of  twenty  and  fifty  they  are  most  common.  Above  fifty  they 
are  rare.  The  ages  of  those  patients  who  died  of  this  disease, 
and  upon  whom  we  have  ourselves  performed  autopsies,  were 
19,  24,  26,  42,  45,  47,  48  and  62,  respectively.  Sarcomata  are 
of  more  frequent  occurrence  in  males  than  in  females, 
although  no  satisfactory  reason  can  be  given  for  this  curious 
fact.  True  carcinoma,  on  the  other  hand,  rarely  occurs  before 
middle  life  and  seems  to  attack  the  sexes  equally. 

Symptoms. — The  symptoms  of  mediastinal  growth  are  due 
to  the  presence  of  a  foreign  mass  within  the  thorax,  diminish- 


PLATE   XXXIV 


SARCOMA  Or    THE  MEDIASTINUM  INVADING  THK 

LUNG 

The  drawing  shows  the  posterior  portion  of  the  right  lung. 
The  lower  lobe  is  seen  to  be  occupied  by  a  large  whitish  mass  of 
new  growth,  which  originated  in  the  bronchial  glands,  and 
spread  thence  into  the  right  lung,  especially  the  lower  lobe, 
extending  along  the  line  of  the  bronchi  by  various  tentacle-like 
processes.  The  growth,  which  proved  on  microscopical  examina- 
tion to  be  a  lympho-sarcoma,  had  invaded  and  almost  obliter"ated 
the  right  bronchus,  and  wa^  also  invading  the  pericardium  and 
the  wall  of  the  right  auricle.  The  right  upper  lobe  was  involved, 
but  the  left  lung  was  free  from  growth.  Secondary  deposits  were 
present  in  both  suprarenals  and  in  the  left  ovary.  The  right 
pleura  showed  some  loose  adhesions  and  contained  a  little  fluid. 

In  addition  to  the  sarcomatous  disease,  the  apex  of  the  right 
lung  was  the  seat  of  recent  tubercle.  In  the  lower  lobe  was  some 
acute  broncho-pneumonia. 

From  a  woman  aged  forty-two,  who  two  months  before  her 
death  was  admitted  into  the  Brompton  Hospital  with  signs  of 
right  pleural  effusion.  Thirty  ounces,  and  later  twenty-six 
ounces,  of  serous  fluid  were  withdrawn,  and  ten  days  before 
death  ten  ounce-  of  blood-stained  fluid.  Death  occurred  after 
attacks  of  urgent  dyspnoea. 


(From  the  Museum  of  the  Brompton  Hospital.     |  natural  size.l 


PLATE  XXXIV 


Sarcoma  of  the  Mediastinum  invading  the  Lung. 


To  face  p.  738. 


INTRATHORACIC  TUMOURS  739 

ing  breathing-  space,  compressing-  vessels  and  nerves,  and 
thrusting  aside  or  invading  important  passages,  organs  and 
tissues.  The  first  symptoms  which  usually  attract  the  patient's 
attention  are  cough  and  gradually  increasing  shortness  of 
breath.  The  cough,  at  first  dry  and  teasing,  or  attended  with 
slight  and  difficult  muco-purulent  expectoration,  presents  no 
special  peculiarity;  but  later,  when  the  growth  compresses  the 
trachea  or  bronchus,  it  acquires  a  pecuhar  "  clanging "  or 
"  brassy  "  character,  which  the  experienced  ear  at  once  detects. 
With  complete  paralysis  of  the  vocal  cord,  following  compres- 
sion of  the  recurrent  laryngeal  nerve,  the  cough  loses  its  ex- 
plosive character  and  becomes  husky  or  "  bovine "  in  char- 
acter. As  the  disease  progTesses,  the  expectoration  becomes 
more  abundant.  When  the  growth  has  invaded  the  lung,  the 
sputum  may  be  sanguineous,  and  it  sometimes  resembles  "  red- 
currant  jelly,"  the  mucus  coughed  up  being  very  intimately 
mixed  with  blood;  but  this  latter  form  of  sputum  is  by  no 
means-  so  essential  to  the  disease  as  is  sometimes  supposed. 
In  certain  cases  profuse  hsemoptyis  has  been  observed,  an 
event  sometimes  preceded  by  the  coughing  up  of  fragments 
of  the  growth,  although  this  is  of  unusual  occurrence.  In 
rare  cases  the  haemoptysis  has  proved  fatal. 

Pain  in  the  chest  is  another  early  symptom  of  which  the 
patient  often  complains.  It  is  sometimes  of  the  darting  char- 
acter peculiar  to  new  growths,  and,  if  the  brachial  plexus  be 
involved,  may  not  be  restricted  to  the  chest,  but  referred  to 
the  shoulder  or  radiate  down  the  arm.  More  generally,  how- 
ever, there  is  a  sense  of  oppression  in  the  chest  rather  than 
of  actual  suffering,  except  in  cases  complicated  with  pleurisy. 

The  more  distinctive  pressure  symptoms  manifested  by 
mediastinal  growths  arise  from  compression  of  the  blood- 
vessels and  lymphatics,  the  trachea  and  bronchi,  the 
oesophagus  and  nerves.  On  anatomical  grounds  it  follows 
that  a  tumour  originating  in  the  anterior  mediastinum  will 
compress  the  veins,  while  one  originating  in  the  bronchial 
glands  will  first  compress  the  posterior  mediastinal  structures, 
giving  rise  to  dyspnoea,  laryngeal  paralysis,  ocular  symptoms 
and  dysphagia.  The  early  pressure  signs  will  therefore 
enable  us  in  some  degree  to  locaHse  the  position  of  the 
tumour.  Towards  the  end  of  the  disease,  with  the  spread  of 
the  growth,  the  pressure  symptoms  become  more  general. 


740  DISEASES   OF  THE  LUNGS   AND  PLEURA 

The  growth  affects  differently  the  arteries  and  veins,  the 
thick  elastic  walls  of  the  former  resisting  its  encroachment, 
whilst  the  thin  walls  of  the  veins  are  easily  compressed  and 
their  lumen  invaded,  the  mass  sometimes  appearing  as  a  warty 
elevation  within  them.  Inequality  of  the  radial  pulses  is, 
accordingly,  not  often  met  with,  whilst  symptoms  of  com- 
pression of  the  superior  vena  cava  or  innominate  vein,  such 
as  oedema,  puffiness  and  lividity  of  the  head,  neck,  and  arms 
(especially  the  right  side),  together  with  enlargement  of  the 
veins  over  the  upper  part  of  the  chest,  are  common.  In 
aneurism,  where  the  disease  affects  the  arterial  wall  itself,  the 
reverse  holds  good. 

When  the  trachea  or  its  main  divisions  are  definitely  com- 
pressed, cough  and  dyspnoea  become  very  marked,  the  cough 
assuming  the  clanging  or  husky  quality  already  described. 
Stridor  also  developes,  and  the  attacks  of  dyspnoea  acquire  a 
most  distressing-  paroxysmal  character,  in  one  of  which  the 
patient  may  succumb.  These  attacks  are  generally  due  to  a 
plug  of  mucus  accumulating  near  the  point  of  compression 
and  blocking-  the  lumen  of  the  tube. 

Dysphagia  is  a  symptom  more  often  complained  of  in 
growths  than  in  aneurism.  The  oesophagus,  however,  is  so 
lax  an  organ  that  it  may  be  stretched  to  a  considerable  extent 
over  a  mass  of  growth  without  any  great  difficulty  in  degluti- 
tion resulting,  and,  provided  it  be  not  invaded,  it  is  rare  for 
this  symptom  to  give  rise  to  serious  trouble. 

The  recurrent  laryngeal  and  the  sympathetic  are  the  nerves 
more  commonly  affected.  Thus,  abductor  paralysis  of  one 
vocal  cord,  to  be  discovered  only  by  largyngoscopic  examina- 
tion, and  later  complete  paralysis,  with  weakening  and  hoarse- 
ness of  the  voice  and  husky  cough,  may  be  observed. 
This,  however,  is  by  no  means  so  frequently  present 
as  in  aneurism;  indeed,  we  have  on  more  than  one 
occasion  seen  the  nerve  completely  embedded  and  appar- 
ently lost  in  a  mass  of  growth  without  its  function 
being  impaired.  Ocular  signs  are  more  common.  If 
the  fibres  of  the  sympathetic,  which  arise  from  the  upper 
dorsal  roots,  be  compressed  and  destroyed,  the  pupil  will  be 
unable  to  dilate,  and  will  appear  smaller  than  its  fellow.  SHght 
drooping  of  the  eyelid,  narrowing  of  the  palpebral  fissure, 
retraction  of  the  eyeball,  and  interference  with  sweating  on 


INTRATHORACIC  TUMOURS  741 

the  affected  side  of  the  head  and  neck,  other  well-known  signs 
of  sympathetic  paralysis,  are  sometimes  also  observed.  The 
interference  with  sweating  may  be  easily  demonstrated  by 
dusting  the  part  with  powdered  charcoal  after  an  injection  of 
pilocarpine.  On  the  healthy  side  the  powder  adheres  to 
the  sweating  surface;  on  the  affected  side  it  is  easily  blown 
away.^ 

Such  are  the  chief  symptoms  which  may  be  noticed  in  a 
case  of  mediastinal  growth.  Emaciation,  excepting  in  those 
rare  cases  in  which  the  oesophagus  is  early  obstructed,  is  not 
a  marked  feature,  although  in  all  cases  some  loss  of  weight 
occurs.  True  cachexia  is  most  uncommon.  Pyrexia  of  a  low 
and  somewhat  irregular  type  is  often  present;  but  in  such 
cases  the  growth  is  rarely  found  after  death  to  be  uncompli- 
cated, bronchiectasis  or  a  slowly  disintegrating  form  of  septic 
broncho-pneumonia  being  most  often  discovered,  and  to  these 
pathological  changes,  rather  than  to  the  growth  itself,  we 
must  attribute  the  pyrexia,  since  in  other  cases  fever  may  be 
entirely  absent  for  weeks  tog'ether. 

Physical  Signs. — The  physical  signs  met  with  in  a  case  of 
mediastinal  growth  will  vary  much,  according  to  the  extent 
of  the  disease.  If  the  growth  be  recent,  and  confined  merely 
to  the  glands,  there  may  be  no  symptoms  or  definite  signs, 
or  at  most  some  impairment  of  note  over  the  manubrium 
sterni  or  the  upper  interscapular  region  behind.  But  as  a 
rule  distinct  physical  signs  appear  before  death.  We  must 
note  at  once,  however,  that  these  signs  are  not  necessarily  due 
directly  to  the  presence  of  the  growth,  but  may  be  the  result 
of  pulmonary  collapse,  pneumonia,  or  bronchiectasis,  with 
thickening  of  the  lung  texture,  produced  by  the  obstruction 
of  bronchi  by  growth  which  has  invaded  their  walls.  The 
occurrence  of  a  secondary  effusion,  either  from  pleurisy  or 
compression  of  veins  or  lymphatics,  often  also  complicates 
the  physical  signs.  Bearing  these  facts  in  mind,  we  may  now 
attempt  to  draw  a  cHnical  picture  of  a  case  of  some  little 
standing. 

A  shghtly  staring,  suffused,  and  anxious  expression  of 
countenance  is  most  commonly  to  be  observed,  and  in  marked 
cases  the  aspect  assumes  that  of  semi-strangulation,  pitiable 
to  witness,  the  swollen  and  oedematous  head,  neck  and  upper 
limbs  contrasting  with  the  natural  appearance  of  the  lower 


742  DISEASES   OF  THE  LUNGS   AND  PLEURA 

half  of  the  body.  The  respirations  are  quickened,  the  pulse 
generally  somewhat  accelerated,  whilst  the  temperature 
remains  normal,  or  is  but  sHghtly  febrile.  When  the  anterior 
portion  of  the  mediastinum  is  involved,  as  is  the  case  in  many 
instances,  some  prominence  of  the  upper  sternum  may  be 
noticed.  Enlargement  of  the  glands  at  the  root  of  the  neck 
or  in  the  axilla  (see  p.  86)  should  always  be  carefully  sought 
for,  this  sign  being-  of  material  assistance  in  diagnosis.  The 
heart  is  displaced  in  a  direction  varying-  with  the  position  of 
the  growth.  Most  commonly  it  is  simply  thrust  to  one  side, 
but  sometimes  the  base  is  lowered,  and  the  apex  tilted  upwards 
and  outwards.  At  other  times  the  growth  extends  from 
above  downwards  between  the  sternum  and  the  heart,  or, 
again,  forwards  from  behind  that  org'an;  and  we  have  met 
with  an  instance  in  which  the  heart  was  thus  borne  for- 
wards, compressed  and  fluttering,  against  the  anterior  chest 
wall. 

Over  the  region  of  the  tumour  there  is  percussion  dulness, 
which,  having-  been  first  observed  in  the  area  of  the  mediasti- 
num, soon  comes  to  encroach  upon  the  limits  of  the  lung.  A 
careful  percussion  of  the  outHnes  of  the  dulness  will  in  most 
cases  reveal  that  the  middle  line  of  the  chest  has  been  trans- 
gressed— a  fact  of  considerable  diagnostic  importance.  A 
certain  impulse  communicated  from  the  aorta  may  often  be 
felt  by  the  hand  or  appreciated  by  the  stethoscope  over  the 
dull  area;  its  knocking  rather  than  expansile  character  can 
usually,  but  not  always,  be  distinguished  from  that  of 
aneurism.  The  heart  sounds  are  well  conducted  by  the 
growth,  and  a  soft  systolic  murmur  or  souffle  is  occasionally 
to  be  heard  over  some  portion  of  the  dull  region. 

The  respiratory  sounds  heard  over  the  tumour  differ  accord- 
ing as  the  bronchus  is  still  patent  or  is  obstructed  by  the 
growth,  which  sooner  or  later  penetrates  the  lumen  of  the 
tube.  In  the  former  case  bronchial  breathing,  sometimes  of 
an  intense  character,  in  other  cases  obscured  by  stridor,  is 
heard  over  the  dull  area,  and  vocal  resonance  and  possibly 
also  fremitus  are  increased.  If  bronchial  obstruction  has 
occurred,  then  the  respiratory  murmur  is  enfeebled  or 
annulled,  and  both  vocal  fremitus  and  resonance  disappear. 
In  such  cases,  on  placing  the  hands  evenly  on  the  two  sides 
over  the  lower  regions  of  the  chest,  impairment  of  mobility 


INTRATHORACIC  TUMOURS  743 

may  be  observed  on  the  affected  side  during  deep  inspiration. 
Enfeeblement  of  breath-sounds  over  one  lung  is  sometimes 
of  diagnostic  significance  in  cases  in  which  there  are  as  yet  no 
other  signs  of  mediastinal  growth. 

As  the  disease  advances,  in  cases  in  which  vital  passages 
are  not  so  immediately  invaded  as  speedily  to  terminate  hfe, 
the  lung  becomes  more  involved  from  root  to  periphery,  until 
the  whole  side  is  completely  dull.  The  chest  may  be  dis- 
tended from  the  pressure  of  the  growth,  but  retraction  of  the 
side  is  by  no  means  uncommon,  either  from  shrinking  of  the 
growth  itself  or  as  the  result  of  secondary  collapse  of  the 
lung.  Should  the  side  be  distended  and  the  case  be  now 
observed  for  the  first  time,  it  may  be  impossible  to  distinguish 
it  from  one  of  extensive  pleuritic  effusion,  for  the  heart  is 
displaced,  as  it  would  be  by  fluid  in  the  pleura,  and  vocal 
fremitus,  resonance,  and  breath-sounds  are  all  suppressed. 
The  introduction  of  a  fine  trocar  which  fails  to  strike  fluid^i. 
and  is  felt  to  penetrate  and  to  be  fixed  by  solid  tissues,  is  the*^ 
only  means  of  effecting-  diagnosis,  although  careful  examina- 
tion will  often  reveal  outlying  islets  of  resonance  correspond- 
ing- with  thin  areas  of  lung  encrusting  the  periphery  of  the 
growth. 

An  X-ray  examination  may  help  to  elucidate  the  diagnosis, 
the  growth  being  revealed  as  a  non-pulsating  shadow  with 
somewhat  irregular  and  ill-defined  edge;  but  in  other  cases 
effusion  into  the  pleura,  either  mechanical  from  pressure  upon 
the  azygos  veins,  or  of  inflammatory  origin,  complicates  the 
signs  and  symptoms  of  the  tumour,  and  obscures  the  X-ray 
picture. 

Such  effusions  are  often  blood-stained,  but  this  has  no  great 
significance,  the  fluid  in  cases  of  simple  pleurisy  being 
often  of  similar  nature.  Of  more  diagnostic  importance  is 
the  cytological  character  of  the  fluid.  In  simple  pleurisy 
with  effusion  a  cytological  count  generally  sho^ys,  as  we  have 
seen  (p.  92),  a  predominance  of  small  lymphocytes.  In 
malignant  disease  small  lymphocytes  are  also  present  in  large 
numbers,  and  the  count  may  closely  resemble  that  of  a  simple 
pleural  effusion.  It  sometimes  happens,  however,  when  the 
pleura  itself  is  invaded,  that  there  may  also  be  observed  cells 
of  large  size  and  irregular  shape,  often  vacuolated  in  appear- 
ance, and  with  the  nucleus  pushed  to   one   side,   giving  a 


744  DISEASES   OF   THE   LUNGS   AND   PLEURA 

"  signet-ring- "  appearance  (see  Plate  XXXV.).  If  such  cells 
are  numerous  and  collected  into  groups,  the  picture  presented 
is  one  very  suggestive  of  maHgnancy. 

A  short  account  of  the  following  cases  will  illustrate 
certain  of  the  points  emphasised  in  the  preceding  para- 
graphs: 

Case  I. — On  March  27,  1904,  one  of  us  saw,  in  consultation  with 
Sir  Thomas  Smith,  and  later  with  Sir  A.  Pearce  Gould  and  Dr.  Whit- 
tick,  a  lady,  aged  forty-eight,  who  complained  of  painful  and  difificult 
deglutition,  with  radiating  pains  about  the  sternum  and  to  the 
shoulders.  The  history  of  her  illness,  rather  obscure  and  indefinite, 
was  as  follows  : 

.  The  lady  was  of  active  habits,  a  good  and  fearless  rider,  and,  except 
for  some  severe  hunting  accidents,  had  enjoyed  excellent  health. 
Two  years  before  she  had  a  bad  fall  from  her  horse,  but  made  a 
good  recovery.  In  November,  1903,  she  suffered  from  influenza,  fol- 
lowed by  pains  below  the  left  breast,  round  the  chest,  and  down 
the  back  and  leg,  which  were  regarded  as  due  to  influenzal  neuritis. 
In  February,  1904,  she  consulted  her  physician  for  symptoms  of  acid 
dyspepsia,  with  occasional  slight  pyrexia  (100°),  gastric  pains  and 
intercostal  tenderness.  There  was  pyorrhoeal  affection  of  the  gums, 
and  the  chest  and  shoulder  pains  were  attributed  to  "  a  septic  infec- 
tion from  alveolar  pyorrhoea  irritating  the  fibrous  tissues  of  the  pleura 
and  oesophagus."  Sufficient  importance  was,  perhaps,  not  attached 
to  the  difficulty  in  swallowing,  or,  rather,  the  sense  of  constriction 
opposite  the  third  piece  of  the  sternum,  attended  with  pain  of  a 
radiating  character,  which  had  existed  for  some  weeks,  until  it 
amounted  to  an  obstruction,  and  which,  on  Sir  Thomas  Smith's 
first  seeing  the  patient  on  March  26,  rendered  partial  feeding  by  the 
rectum  necessary.  At  this  time  a  short  cough  had  supervened,  and 
there  was  occasional  retching  with  the  removal  of  mucus,  slightly 
tinged  with  blood  and  containing  some  purulent  opacities. 

On  March  27  the  following  conditions  were  noted  :  The  patient  had 
passed  a  restful  night  owing  to  morphia,  but  there  had  been  slight 
retching  of  lightly  stained  mucus.  The  countenance  was  pale,  with 
no  marked  anxiety  of  feature;  respirations  quiet,  although  sHghtly 
quickened;  breath  notably  foetid.  The  pulse  was  small  and  com- 
pressible (she  had  been  fed  by  enemata  for  the  last  sixteen  hours). 
There  was  also  occasional  slight  cough  with  expectoration  of  mucus 
containing  a  few  pus  and  blood  corpuscles.  On  giving  her  a  little 
milk  to  drink,  an  evident  difficulty  in  the  passage  was  experienced 
at  about  the  junction  of  the  upper  and  middle  third  of  the 
oesophagus,  and  some  pain  was  complained  of  in  the  effort  of  swallow- 
ing. The  milk  was  not,  however,  returned.  Over  an  area  cor- 
responding with  the  upper  portion  of  the  sternum  to  the  level  of  the 
third   cartilage,    and   extending   to   the   left   for   an   inch   beyond   the 


PLATE  XXXV 


CELLS  FROM  A  CASE  OF  PLEURAL  EFFUSION  OF 
MALIGNANT  ORIGIN 

The  cells  were  obtained  by  centrifugalising  the  fluid  removed 
from  the  pleura  during  life.  From  a  female  patient,  aged  forty- 
seven,  who  died  from  new  growth  of  the  lung  and  pleura.  The 
large  size  of  the  cells,  their  irregular  shape,  dropsical  appear- 
ance, and  the  expression  of  the  nucleus  to  one  side,  producing  a 
"  signet-ring  "  appearance,  suggested  the  presence  of  malignant 
growth,  which  was  confirmed  at  the  autopsy. 

(Drawing  by  Dr.  I.  C.  Maclean,  from  a  preparation  by  Dr. 
A.  C.  Inman;  stained  by  Giemsa's  modification  of  Romanowsky's 

stain.      X  750.) 


PLATE  XXXV. 


Cells  from  a  case  of  Pleural  effusion 
of  malignant  origin. 


To  /ace  page  744 


INTRATHORACIC  TUMOURS  745 

sternal  margin,  there  was  dulness,  and,  on  application  of  the  hand, 
a  slightly  heaving  impulse,  which  was  more  distinctly  appreciated 
by  the  finger-tips  pressed  into  the  interspaces  at  the  left  sternal 
margin.  The  expansile  impulse  was  still  more  evident  to  the  ear, 
using  the  solid  stethoscope,  and  with  each  impulse  there  was  a  bruit 
de  souffle  closely  resembling  in  character  the  placental  murmur.  The 
heart's  position  was  normal,  and  there  were  no  altered  cardiac  sounds. 
The  respiration  over  the  left  front  was  weak  and  sub-bronchial  in 
quality,  and  generally  over  the  left  side  posteriorly  the  percussion 
note  was  less  full  and  the  respiration  weakened,  becoming  in  the 
lower  interscapular  region  somewhat  bronchial  in  quality  and  accom- 
panied by  a  few  crepitations.  On  the  right  side,  both  in  front  and 
behind,  the  respiratory  sounds  were  exaggerated. 

The  diagnosis  arrived  at  was  that  there  was  a  soft  and  rapidly 
growing  and  very  vascular  tumour  in  the  anterior  mediastinum, 
pressing  upon  and  more  or  less  involving  the  oesophagus,  and  com- 
mencing to  invade  the  rest  of  the  lung.  In  the  male  subject  an 
aneurism,  especially  of  the  dissecting  kind,  might  have  been  more 
seriously  in  question,  particularly  with  the  history  of  a  severe  hunting 
accident ;  but  there  were  no  signs  of  alteration  of  the  cardio-vascular 
system  and  no  accentuation  of,  or  murmur  with,  the  second  sound 
of  the  heart.  The  possibility  of  a  pulsating  mediastinal  abscess  had 
more  carefully  to  be  considered ;  and,  although  the  bruit  seemed  to 
be  so  distinctly  intrinsic  to  the  tumour,  and  there  was  an  absence  of 
any  marked  excursion  of  temperature  or  hectic  symptoms,  still,  the 
possibility  could  not  altogether  be  ignored,  and  the  patient  volun- 
teered the  statement,  without  any  suggestive  questions,  that  she  felt 
a  throbbing  as  of  an  abscess  within  her  chest. 

It  was  agreed  that  some  exploration  should  be  made,  and  Sir  A. 
Pearce  Gould  was  asked  to  see  her  on  the  following  morning  with 
this  intention.  Meanwhile  Dr.  Hugh  Walsham  was  requested  to 
take  a  skiagram,  from  which  the  evidence  of  the  conditions  being 
due  to  growth,  not  fluid,  was  strengthened.  On  March  29,  after 
careful  consultation,  it  was  decided  that  the  safer,  as  well  as  the  more 
satisfactory,  plan  was  to  raise  the  sternal  end  of  the  pectoral  muscle, 
and  make  an  incision  through  the  intercostal  space.  An  aneesthetic 
was  given,  and  the  sternal  attachment  of  the  muscle  having  been 
divided,  the  second  cartilage  was  exposed,  and  on  cutting  through 
the  space  it  was  at  once  obvious  that  a  soft  growth  was  underneath. 
The  second  cartilage  was  excised  with  a  view  to  relieve  pressure, 
which  enabled  the  growth  to  be  further  examined,  and  the  wound 
was  then  closed  and  stitched  up.  The  structure  of  a  fragment  of 
the  growth  removed  proved  on  examination  to  be  that  of  a  round- 
celled  sarcoma,  extremely  vascular  and  presenting  numerous  haemor- 
rhagic  extravasations.  Some  decided  temporary  relief  was  afforded 
by  the  removal  of  the  cartilage,  and  the  consequent  diminution  of 
internal  pressure,  and  the  lady  took  some  food  afterwards  with  but 
little  difficulty.     She  died,  however,  nine  days  after  the  operation. 


746  DISEASES   OF  THE  LUNGS  AND  PLEURA 

Case  II. — The  following  case  shows  the  disease  com- 
mencing with  the  features  of  simple  pleural  effusion,  as  so 
often  happens : 

Mrs.  T.,  aged  fifty-six,  was  seen  with  Dr.  Farr  on  November  5, 
1909.  She  had  suffered  from  influenza  twelve  months  previously,  and 
had  been  ailing  since.  In  the  previous  August  she  went  to  Llan- 
drindod.  On  October  29  the  respirations  were  stated  to  have  been  28, 
and  some  friction  was  heard  over  the  pericardium.  At  the  time  of  the 
consultation  on  November  5  there  was  a  paroxysmal  cough,  but  no 
expectoration ;  the  temperature  was  99° ;  the  urine  phosphatic.  On 
examination  the  right  side  of  the  chest  was  found  to  be  dull  over 
the  anterior  base,  and  the  left  dull  to  the  angle  of  the  scapula. 

On  November  10  the  dulness  had  extended  upwards  on  the  left 
side.  Skodaic  resonance  was  elicited  below  the  clavicle,  and  over 
the  upper  confines  of  dulness  behind  at  the  mid-scapular  region  the 
breathing  was  tubular ;  the  dypsnoea  was  considerable.  The  physical 
signs  thus  far  pointed  to  simple  effusion,  and  a  pint  of  fluid  was  with- 
drawn, tinged  with  blood,  which  it  was  thought  might  be  due  to  the 
rupture  of  a  small  vessel  during  the  operation. 

By  November  20  the  effusion  had  again  increased  up  to  the  clavicle, 
and  grave  doubts  were  now  expressed  as  to  growth  being  in  the 
background,  owing  to  the  slightness  of  the  febrile  reaction,  the 
insidious  onset  of  the  illness,  and  the  blood-stained  fluid.  A  further 
tapping  was  recommended.  This  resulted  in  the  withdrawal  of  but 
twelve  ounces  of  fluid,  which,  according  to  the  report  of  the  Clinical 
Research  Association,  "  contained  a  moderate  amount  of  blood  and 
a  small  clot,  also  coagulated  lymph,  and  many  small  masses  com- 
posed of  cells  of  variable  size  and  more  or  less  irregular  shape.  Cells 
mostly  rounded,  much  vacuolated,  and  degenerated.  No  pus  cells, 
tubercle  bacilli,  or  other  organisms  were  found.  The  characters  of 
the  fluid  are  almost  pathognomonic  of  growth."  Dr.  Farr  added, 
in  sending  the  report:  "  I  think  the  growth  has  much  increased; 
she  is  now  so  much  distressed  with  urgent  dyspnoea  that  I  have  com- 
menced morphia  injection."     The  patient  died  shortly  after. 

Case  III. — The  following  case  was  one  in  which  the  diag- 
nosis of  mediastinal  growth  emerged  through  that  of  em- 
physema and  dilated  heart,  from  which  the  patient  had  for  ten 
years  been  known  to  suffer : 

Mr.  O.,  aged  forty-eight,  was  seen  with  Sir  Malcolm  Morris  in 
October,  1905,  the  patient  having  been  under  observation  since  1896 
for  emphysema.  In  November,  1905,  he  was  sent  to  Torquay,  where 
he  became  less  well,  with  increasing  difficulty  of  breathing,  especially 
at  night;  he  also  had  some  attacks  of  dark  haemoptysis  of  not  more 
than  half  an  ounce  in  amount.  At  the  end  of  August,  1906,  he  was 
again  seen,  and  the  signs  obser\^ed  were  those  of  general  emphysema, 


INTRATHORACIC  TUMOURS  747 

but  with  less  fulness  of  note  over  the  right  side,  and,  over  the  lowest 
three  ribs  posteriorly,  dulness,  regarded  as  due  to  collapse  of  lung 
from  pressure  of  a  somewhat  enlarged  liver,  which  was  palpable  for 
two  fingers'  breadth  below  the  costal  margin.  The  right  side  of  the 
heart  was  dilated,  and  a  systolic  murmur  was  audible  at  the  apex. 

On  November  8,  1906,  he  was  again  examined  with  Sir  Malcolm 
Morris,  when  a  notable  absence  of  breath-sound  was  observed  over 
the  right  side  of  the  chest,  and  some  dulness  was  noted  in  the  right 
interscapular  region.  The  first  diagnosis  of  emphysema,  mitral 
incompetence,  dilated  heart,  and  pulmonary  infarction,  was  now 
supplemented  by  that  of  posterior  mediastinal  growth  to  which  the 
haemorrhagic  attacks  were  attributable.  The  disease  made  rapid 
progress  to  a  fatal  issue.  The  temperature  hovered  between  the 
normal  and  99°. 

Case  IV. — The  following  case,  one  of  aneurism  of  the 
transverse  aorta,  presented  many  of  the  features  of  medias- 
tinal grow^th,  or  possibly  of  abscess  behind  the  sternum,  and 
therefore  may  perhaps  be  usefully  introduced  here : 

Captain  C,  aged  fifty,  was  seen  with  Dr.  Humphrey  on  March  4, 
1897.  There  was  a  history  of  syphilis,  and  he  had  led  physically  a 
strenuous  life.  In  February,  1895,  he  had  laryngitis,  and  suffered 
for  twelve  months  from  some  asthmatic  symptoms.  In  September 
of  that  year  he  coughed  up  three-quarters  of  a  pint  of  pus,  and  since 
then  had  had  eight  similar  attacks,  the  last  in  December,  1896.  The 
expectoration  had  been  purulent  since  then,  but  not  foetid,  and 
occasionally  more  purely  bronchial  mucus  had  been  expectorated.  Of 
late  he  could  only  sleep  in  the  sitting  posture.  His  weight  had 
diminished  from  11  stone  to  9  stone  12  pounds. 

The  features  were  congested  to  turgescence,  and  there  was  very 
considerable  distress  in  breathing.  Over  the  manubrium  sterni,  and 
a  little  to  right  and  left  of  it,  there  was  dulness,  and  pulsation  was 
felt  over  a  small  area  corresponding  with  the  inner  end  of  the  second 
cartilage  and  left  space.  Posteriorly,  in  the  interscapular  region  on 
either  side  and  over  the  spine  as  far  as  the  fourth  process  the  breath- 
sounds  were  notably  bronchial. 

As.  regards  the  diagnosis  in  this  case  there  was  some  difference  of 
view,  that  which  appeared  to  us  most  probable  being  that  of  a  saccu- 
lated aneurism  presenting  from  the  back  part  of  the  transverse  aorta, 
pressing  upon  the  lower  trachea,  and  causing  muco-purulent  secre- 
tion to  accumulate  behind  it;  the  other  view  being  that  there  was 
an  abscess  or  growth  in  the  upper  substernal  region  connected  with 
the  bronchus,  and  having  pulsation  communicated  to  it  from  the 
vessel.  This  latter  view  was  favoured  by  the  report  of  an  X-ray 
examination. 

The  patient's  symptoms  becoming  aggravated,  it  was  decided,  in 
consultation  with  Sir  Alfred  Pearce  Gould,  to  explore  the  upper  medi- 


748  DISEASES   OF  THE  LUNGS  AND  PLEURA 

astinum,  and  on  March  30,  1897,  Sir  Alfred  trephined  the  manubrium 
sterni,  and  dissected  down  to  the  aorta.  "  No  abscess  or  swelling 
was  detected;  the  aorta  appeared  very  large,  and  pulsation  was  felt 
all  round  the  finger."  The  wound  was  then  closed.  On  April  10 
the  patient  went  to  Brighton.  "The  operation  did  neither  good  nor 
harm;  if  anything,  he  was  more  comfortable  afterwards."  From  a 
report  kindly  furnished  by  Dr.  Halstead,  who  had  the  care  of  Cap- 
tain C.  for  some  time  before  the  operation  and  subsequently  at 
Ramsgate,  it  appeared  that  there  was  no  discharge  of  pus  after  the 
operation,  with  the  exception  of  a  few  drachms  in  July,  until  about  a 
fortnight  before  his  death,  during  which  time  Captain  C.  brought 
up  daily  approximately  four  ounces  of  muco-pus  and  suffered  much 
distress.     He  died  from  exhaustion  on  September.  26,  1897. 

Diagnosis. — The  diagnosis  of  tumour  of  the  mediastinum, 
as  soon  as  symptoms  seriously  draw  attention  to  the  case,  is 
not  as  a  rule  difficult,  since  pressure  signs  and  symptoms  are 
incompatible  with  any  other  form  of  pleuritic  disease  or  pul- 
monary consolidation,  nor  are  they  present  in  any  decided 
degree  even  in  extreme  pericardial  effusion. 

The  conditions  which  most  simulate  tumours  in  this  region 
are  abscess  of  the  mediastinum  and  syphilitic  stricture  of  a 
main  bronchus.  With  abscess  the  temperature,  hectic  pheno- 
mena, possible  history  of  injury,  the  character  of  the  pain, 
and  the  attendant  inflammatory  phenomena,  will  usually 
clear  up  the  difficulty,  although  we  have  already  described  a 
case  in  which  abscess  decidedly  entered  into  the  question  of 
diagnosis,  and  another  case  in  which  the  diag'nosis  between 
an  abscess  beneath  the  sternum  and  an  aneurism  was  only 
decided  in  favour  of  the  latter,  and  contrary  to  the  interpre- 
tation of  an  X-ray  examination,  after  a  portion  of  the  sternum 
had  been  trephined.  The  distinction  of  syphilitic  stricture  of 
the  main  bronchus  or  lower  trachea  from  an  obscure  medias- 
tinal tumour  of  small  dimensions  strangulating  these  parts  is 
most  difficult.  Still,  the  limitation  of  pressure  signs  to  one 
system  and  the  absence  of  any  discoverable  signs  of  tumour, 
together  with  a  history  of  syphilis,  should  at  least  aid  the 
diagnosis  sufficiently  to  suggest  a  definite  treatment,  the 
effects  of  which  may,  perhaps,  though  not  necessarily,  throw 
further  light  upon  the  case. 

Having  excluded  mediastinal  abscess  and  syphilitic  stric- 
ture, and  arrived  at  the  conclusion  that  a  tumour  is  present, 
we  have  yet  to  determine  whether  it  be  aneurism  or  growth. 


INTRATHORACIC  TUMOURS  749 

In  favour  of  growth  the  following-  are  the  more  important 
points:    (i)   the  age  of  the  patient   (if  below  twenty-five); 

(2)  the  presence  of  an  extensive  area  of  superficial  dulness; 

(3)  the  presence  of  decided  venous  obstruction;  (4)  the  absence 
of  marked  disease  of  the  arteries,  of  characteristic  pulsation, 
diastolic  shock,  tracheal  tugging,  and  a  history  of  syphilis; 
and  (5)  the  history  or  presence  of  tumours  in  other 
situations.  In  a  doubtful  case  an  X-ray  examination 
should  always  be  made.  With  growth  we  see  a  shadow, 
which  in  early  cases,  before  pulmonary  and  pleural  com- 
plications have  set  in,  fades  gradually  at  the  edges,  and 
presents  no  clear  evidence  of  pulsation;  with  aneurism  we 
may  perceive  a  tumour  clearly  defined  in  shape,  and  evincing 
definite  expansile  pulsation,  a  combination  which,  when  clearly 
visible,  is  very  characteristic. 

The  diagnosis  of  new  growth  from  pleural  effusion,  which 
is  sometimes  so  difficult,  must  be  settled,  as  we  have  seen,  by 
the  exploring  syringe;  but  we  must  remember  that  the  two 
are  not  infrequently  combined.  In  such  cases  a  microscopic 
examination  of  the  cells  present  in  the  fluid  (see  p.  743)  may 
prove  of  value,  as  in  one  of  the  cases  which  we  have  just 
recorded. 

With  regard  to  the  nature  of  the  growth,  it  is  to  be  remem- 
bered that,  if  the  disease  be  primary  in  the  mediastinum,  it 
will  probably  be  a  sarcoma,  and  the  younger  the  patient,  the 
more  likely  is  this  to  prove  the  case.  Should  the  disease  be 
secondary  to  a  growth  elsewhere,  it  will  be  of  the  same  nature 
as  the  primary  disease. 

Prognosis. — Malignant  disease  of  the  mediastinum  is  inevit- 
ably fatal,  but  its  duration  varies  much.  Of  sixty  cases 
occurring  at  the  Brompton  Hospital,  investigated  by  Dr.  J.  N. 
MacBean  Ross,^  the  average  duration  of  life  from  the  date 
of  the  first  symptom  complained  of  was  thirty-two  weeks, 
the  maximum  duration  being  eighty-eight  weeks,  and  the 
minimum  nine.  Death  is  generally  the  result  either  of 
gradual  exhaustion  or  of  suffocation,  the  patient  in  the  latter 
case  dying  after  prolonged  attacks  of  dyspncea.  Less  com- 
monly it  is  due  to  haemoptysis,  sudden  syncope,  or  cerebral 
tumour.  At  the  post-mortem  the  disease  may  be  found 
restricted  to  the  mediastinum  and  lung,  but  it  is  more  com- 
mon to  discover  secondary  growths  elsewhere,  the  liver,  pan- 


750  DISEASES  OF  THE  LUNGS  AND  PLEUR.E 

creas,  suprarenals  and  kidneys  being  the  organs  most  com- 
monly attacked. 

Treatment. — The  cases  of  mediastinal  new  growth  which 
we  have  been  considering  are  beyond  the  reach  of  surgery, 
and  their  progress  is  not  influenced  by  drug  treatment. 
X-rays  and  radium^  are  not  capable  of  arresting  the  disease, 
but  we  believe  that  in  more  than  one  instance  we  have  seen 
the  progress  of  the  malady  checked  and  the  fatal  issue  some- 
what postponed  by  the  use  of  one  or  other  of  these  remedial 
agents.  We  accordingly-  as  a  rule  advise  in  these  cases  a 
course  of  radium  or  X-ray  treatment. 

The'  more  distressing  symptoms  complained  of,  including 
the  paroxysms  of  dyspnoea,  must  be  relieved  by  sedative 
remedies.  A  combination  which  we  have  used  with  consider- 
able advantag'e,  at  least  for  a  time,  is  one  of  iodide  of  sodium, 
from  three  to  five  grains,  and  chloral,  live  to  ten  grains,  taken 
four  or  six  times  in  the  twenty-four  hours.  Morphia,  in  com- 
bination with  atropine,  must  also  be  employed  and  pushed  if 
necessary.  Temporary  relief  to  the  dyspnoea  may  also  be 
given  by  oxygen.  Should  an  effusion  into  the  pleura  occur, 
it  must  be"  aspirated,  if  it  definitely  increases  the  diffi- 
culty of  breathing;  otherwise  it  is  best  left  alone,  for  it  does 
no  harm,  and  if  removed,  it  will  almost  certainly  recur. 


Tumours  of  the  Lungs. 

In  the  description  which  we  have  just  given  of  mediastinal 
tumours  we  have  shown  that  in  the  great  majority  of  cases, 
before  death  occurs,  the  disease  spreads  into  the  lung,  and 
forms  there  a  mass  of  growth,  often  of  very  considerable 
size.  We  have  now  to  consider  those  tumours  which  may 
affect  the  lung  irrespective  of  the  mediastinum,  or  only  spread 
into  the  latter  at  a  later  date. 

Tumours  of  the  lung  proper,  like  those  of  the  mediastinum, 
may  be  innocent  or  malignant.  Among  the  former,  fibromata, 
lipomata,  and  others,  have  been  described;  but  they  are  all  so 
excessively  rare,  grow  so  slowly,  and  cause  so  few  symptoms, 
that  the  group  possesses  no  clinical  importance,  and  we  shall 
not  again  refer  to  them.  Hydatids,  dermoid  growths,  and 
gummata  we  have  described  elsewhere. 

Primary  Carcinoma  of  the  lung  is  not  so  rare  as  is  com- 


PLATE   XXXVI 


Secondary  Chondro-Carcinoma  of  Lung. 


To  face  p.  751. 


INTRATHORACIC  TUMOURS  751 

monly  supposed,  Dr.  Adler'''  having  recently  collected  374 
examples.  The  disease,  hke  mediastinal  new  growth,  is  more 
common  in  males  than  in  females,  and  usually  occurs  in 
patients  over  the  age  of  forty.  It  originates  most  commonly 
in  the  epithelium  of  the  bronchi,  more  rarely  from  the  cells 
lining  the  alveoli,  and  gives  rise  either  to  a  large  mass  within 
the  lung,  or,  as  in  a  case  which  we  have  recorded,'*  to  an 
infiltration  of  a  portion  of  the  organ.  In  other  cases  the 
growth  commences  in  the  bronchi  near  the  root  of  the  lung 
and  soon  gives  rise  to  symptoms  of  compression.  In 
secondary  cases,  which  are  often  met  with,  the  tumours  gen- 
erally form  numerous  separate  masses,  scattered  throughout 
both  lungs  in  a  fairly  symmetrical  manner,  and  on  section 
varying  in  size  from  that  of  a  threepenny-piece  to  a  shilling 
or  even  larger  (Plate  XXXVI.).  In  rare  cases  the  secondary 
growths  may  be  extremely  small  and  very  numerous,  so  as  to 
resemble  miliary  tubercles,  and  to  this  condition  the  name 
"carcinomatosis"  has  been  applied. 

Primary  sarcoma  originating  in  the  lung  is  undoubtedly 
very  rare,  most  cases  which  seem  at  first  to  suggest 
this  origin  proving  on  investigation  to  be  examples 
of  mediastinal  disease,  with  subsequent  invasion  of  the 
organ.  Nevertheless,  true  examples  occur  from  time  to 
time.  In  such  cases  the  growth  forms  as  a  rule  a 
solid  mass,  which  more  or  less  replaces  the  lung  tissue 
of  a  whole  lobe,  whilst  the  bronchial  and  mediastinal 
glands  remain  unaffected,  or  show  signs  merely  of  recent 
invasion.  Secondary  sarcomata,  on  the  other  hand,  are  com- 
mon, and  they,  too,  Hke  secondary  carcinomata,  are  generally 
multiple  and  bilateral.  Occasionally,  however,  they  take  the 
form  of  single  massive  tumours,  which  give  rise  to  all  the 
symptoms  of  pleural  effusion.  Of  the  large  displacing 
tumours,  osteo-  or  chondro-sarcomata  are  the  most  common, 
and  are  generally  secondary  to  affections  of  bone  or  joints. 

Symptoms.— Vv'imdiry  malignant  disease  of  the  lung  pre- 
sents symptoms  which  closely  resemble  those  which  we  have 
seen  to  occur  in  mediastinal  new  growth.  Cough  and  short- 
ness of  breath,  often  paroxysmal  in  character,  and  pain  in  the 
side,  are  commonly  complained  of;  emaciation  is  not  a  marked 
feature,  and  pyrexia  in  uncomplicated  cases  is  usually  absent. 
The  sputum  is  from  time  to  time  blood-stained,  and  decided 


752  DISEASES   OF  THE  LUNGS   AND  PLEURA 

haemoptysis  may  occur.  Symptoms  of  venous  compression 
and  pressure  on  the  nerves  and  large  air-tracts  are,  however, 
less  frequent  and  longer  delayed  than  in  ordinary  mediastinal 
tumours,  although,  if  the  patient  survive  and  the  mediastinum 
become  affected,  they  may  make  their  appearance. 

The  physical  signs,  again,  are  in  no  sense  characteristic. 
Over  the  portion  of  lung  affected  impaired  note,  weak  breath- 
ing", and  diminished  vocal  vibrations,  or  in  other  cases  bron- 
chial breath-sounds  and  bronchophony,  according  as  the 
bronchus  is  obstructed  or  free,  will  be  the  signs  ehcited.  In 
other  words,  we  have  a  gradual  consolidation  of  the  lung, 
usually  of  the  lower  lobe,  proceeding  from  above  downwards, 
with,  in  most  cases,  weakened  breath-sounds  and  hasmorrhagic 
sputum.  An  X-ray  examination,  provided  it  be  undertaken 
early  in  the  course  of  the  case  and  that  there  is  no  effusion 
into  the  pleura,  discloses  the  shadow  of  the  tumour,  some- 
what irregular  in  outline,  and  often  with  an  ill-defined  edge. 
Later,  with  associated  collapse  of  the  lung  and  other  pul- 
monary and  pleural  changes,  the  X-ray  picture  becomes 
obscured. 

Secondary  growths  in  the  lungs  from  a  primary  focus  in 
some  distant  organ,  even  when  numerous  and  scattered 
through  both  lungs,  not  uncommonly  remain  latent,  the  con- 
dition being  first  discovered  on  the  post-mortem  table.  When, 
however,  the  growth  forms,  as  it  occasionally  does,  a  large 
single  mass,  physical  signs  often  suggesting  a  pleural  effusion 
will  make  their  appearance. 

In  duration  and  mode  of  death  cases  of  primary  malignant 
growth  in  the  lung  do  not  differ  materially  from  those  in 
which  the  mediastinum  is  first  attacked.  Eight  to  ten  months 
is  the  average  duration  of  the  disease;  gradual  asthenia  and 
suffocation  the  common  precursors  of  death. 

Treatment  will  be  similar  to  that  for  mediastinal  growth 
(p.  750).  In  cases  diagnosed  quite  early,  in  which  the  disease 
appears  localised  and  the  mediastinum  not  as  yet  involved, 
surgical  intervention  has  been  essayed  in  a  few  cases,  the 
tumour  and  affected  lobe  of  the  lung  being  removed.  In  one 
case^*  the  patient's  life  was  apparently  somewhat  prolonged, 
but  the  operation  is  so  grave  and  hazardous  that  there  can  be 
but  very  few  cases  for  which  it  would  be  suitable. 


INTRATHORACIC  TUMOURS  753 

REFERENCES. 
^  Mediastinal  Disease,  by  H.  A.  Hare,  M.D.     Philadelphia,   1889. 

^  Treatise  on  Diseases  of  the  Lungs  and  Pleura,  by  Wilson  Fox,  M.D., 
F.R.S.,  p.  1167.     London,  1891. 

^  "  Some  Observations  upon  Primary  New  Growths  of  the  Mediastinum 
from  the  Study  of  Sixty  Cases,"  by  J.  N.  MacBean  Ross,  M.D.  (Edin.), 
The  Edinburgh  Medical  Journal,  1914,  N.S.,  vol.  xiii.,  p.  444.  , 

*  Re-port  on  the  Work  of  the  Pathological  Defartjnent  of  the  Brom-pton 
Hospital  during  the  Three  Years  1900-1903,  by  P.  Horton-Smith  (Hartley), 
M.D.,  p.  30.     London,  1903. 

^  "  Intrathoracic  Tumours  and  Aneurysms  in  their  Clinical  Aspect,"  by 
Graham  Steell,  M.D.,  F.R.C.P.,  The  Lancet,  1911,  vol.  ii.,  p.   1610. 

^    {a)    Primary    Malignant    Growths    of    the    Lungs    and    Bronchi,    by 
I.  Adler,  A.M.,  M.D.,  p.  14.     London,  1912. 
[b)  Loc.  cit.,  p.  108. 


48 


INDEX  OF  AUTHORITIES 


Abrahams,   Adolphe,   201,  331,  332, 

334 
Abrams,  Albert,  349,  351,  472 
Acland,  T.  Dyce,  208,  221,  410 
Adams,  Francis,  84,  89,  590 
Addison,  Thomas,  19,  466,  473 
Adler,  I.,  75i,  753 
Alexander,  J.,  431,  442 
Alexandre,  R.,  710 
AUard,  91 

AUbutt  and  RoUeston,  410 
Andrew,  705 
Andrewes,  F.  W.,  343 
Appleby,  405 
Aretaeus,  79,  86,  89,  573 
Arkle,  C.  J.,  415,  417 
Arloing,  589 
Armit,  H.  W.,  572,  592 
Arneth,  503 
Aron,  8 

Auenbrugger,  L.,  35,  65 
Avery,  Oswald  T.,  321 

Babes,  422 
Baccelli,  120,  132 
Ballin,  428,  442 
Bandelier,  714,  718 
Barcroft,  D.  M.,  366,  378 
'  Bardswell,  N.  D.,  613,  614,  618,  626, 
629,  630,  631,  635,  716,  718 
Barnett,  L.  E.,  378 
Barr,  Sir  J.,  115,  117,  350,  351 
Barrs,  A.  G.,  91,  116 
Bashford,  E.  F.,  187,  202,  331,  334 
Battle,  W.  H.,  132 
Baumgarten,  427 
Baxter,  J.  H.,  24,  32 
Bayard,  F.  Campbell,  176,  220 
Bayle,  420 
Beau,  49,  65 
Beck,  Max,  582,  591 
Beevor,  Sir  Hugh,  436,  437, 443 
Behring,  von,  431 
Bennett,  Hughes,  674 
Bernstein,  J.  M.,  410 
Bert,  Paul,  9,  20 


Besson,  A.,  417 
Bettmann,  Milton,  197,  201 
Beurmann,  L.  de,  411,  413 
Biach,  Alois,  134,  155 
Bierman,  197 
Birch-Hirschfeld,  429 
Bodin,  E.,  418 
Bodington,  George,  607,  617 
Bollinger,  O.,  394,  409 
Bondet,  A.,  50,  54,  65 
Bouchard,  C,  131,  320,  547,  687,  693 
Bowditch,  H.  I.,  109,  450,  461 
Boyce,  R.,  418 
Boyd,  Stanley,  442 

Bradford,  Sir  J.  Rose,  159,  164,  165, 
187,  201,  331,  334,  347,   348,   349, 
350 
Braham,  Noel,  241 
Brauer,  719 
Braun,  Julius,  285 
Brehmer,  607 
Breton,  M.,  591 
Brickdale,  J.  M.  Fortescue-,  161,  165 

Brissaud,  131,  320 

Bristowe,  J.  S.,  46,  378 

Brodie,  Sir  B.,  239,  241 

Brodie,  T.  G.,  243,  244,  268,  705,  710 

Brown,  G.  Gordon,  644,  652 

Brown,  W.  Langdon,  705,  710 

Brown,  Lawrason,  591,  627,  628,  635 

Brown,  A.  Samler,  644,  652 

Browne,  Sir  J.  Crichton-,  447 

Brownlee,  436,  437,  450,  453,  455,  457, 
458,  459,  461 

Bruce,  Mitchell,  516 

Briinings,  W.,  19,  237 

Brunton,  Sir  Lauder,  381 

Buchanan,  Sir  G.,  450,  451 

Buhl,  421 

Bull,  Peter,  728,  731 

Buller,  J.  F.,  50,  65 

Bulloch,  W.,  423,  441,  584 

Bulstrode,  H.  T.,  453,  461,  619,  634 

Burghard,  F.  F.,  366 

Burrell,  L.  S.  T.,  720 

Burton,  450 

754 


INDEX   OF  AUTHORITIES 


755 


Calmette,  A.,  339,  343,  431,  579.  583, 

591 
Calvert,  James,  686 
Campbell,  Colin,  219,  222 
Canti,  R.  G.,  471 
Carling,  Esther,  727,  730 
Carson,  J.,  7,  20 
Castellani,  Aldo,  180,  200 
Cayley,  V/.,  362,  366,  556,  719 
Celsus,  420 

Chambers,  A.  J.,  200,  239 
Chaplin,  Arnold,  217,  222 
Chapman,  J.  E.,  613,  614,  618 
Charcot,  547 
Charles,  603 
Charpy,  A.,  20,  21,  89 
Chausse,  P.,  429,  442 
Chauveau,  A.,  50,  54,  65 
Chickering,  H.  T.,  321 
Clark,  Sir  Andrew,  73,  247,  511,  520 
Clayton,  F.,  201,  334 
Coats,  Joseph,  285 
Cobbett,  Louis,  343,  427,  431,  432,  433, 

441,  460,  473 
Coghill,  J.  Sinclair,  686 
Cole,  Rufus,  321 
Collie,  Sir  John,  410 
CoUingswood,  35,  322 
Collis,  G.  L.,  343 
Cornet,  429 
Corvisart,  35 
Cotton,  548,  556 

Coupland,  Sidney,  132,  289,  321,  476 
Courmont,  Paul,  589,  592 
Craighead,  J.  W.,  724 
Crookshank,  397,  401,  402,  410 
Cuneo,  B.,  19,  85,  86,  89 
Curie,  David,  678,  686 
Curschmann,  H.,  77,  242 

Dally,  Halls,  345 

Dangschat,  Bruno,  384 

Davidson,  Sir  Mackenzie,  64,  230 

Davies,H.  Morriston,  114,117,  221,  222 

Davy,  John, 139,  156 

Delbret,  Pierre,  283,  285 

Delorme,  E.,  129,  132 

Denison,  Charles,  638,  652 

Derry,  D.  E.  J.,  419,  440 

D'Espine,  44 

Dettweiler,  607 

Devillers,  Louis,  415,  417 

Dewar,  Sir  James,  639 

Dickinson,  W.  H.,  568,  572 

Dieulafoy,  109 

Dixon,  W.  E.,'243,  244,  268,  686,  705, 

710 
Dochez,  A.  R.,  321 
Dodwell,  P.  R.,  541,  545 
Donders,  F.  C,  7,  8,  20 
Douay,  G.,  285 


Douglas,  C.  Gordon,  5,  20 
Dreschfeld,  J.,  304,  322 
Dudgeon,  L.  S.,  591 
Dunbar,  248,  249,  261,  262 
Duncan,  Andrew,  156 
Durham,  A.  E.,  238,  240 
Dupuytren,  373 

Edwards,  Vertue,  436 
Ehrlich,  P.,  423,  570 
Eichhorst,  91,  116 
Eicken,  Carl  von, 238, 240 
Elderton,  Ethel  M.,  438,  443 
Elderton,  W.  P.,  625,  626,  629,  630, 

631,  635,  717,  718 
Elliott,  T.  R.,  77,  157,  160,  162,  163, 

164,  165,  349, 351 
Ellis,  Calvin,  117 
Estlander,  J.  A.,  132 
Evill,  484,  485  -  ■  , 

Ewald,  C.  Anton,  2,  19,  44,  139,  156, 

197 
Eyre,  J.  W.  H.,  201,  325,  334 

Fabyan,  Marshall,  117 

Fagge,  Hilton,  46 

Fanning,  F.  W.  Burton,  621,  634 

Farr,  746 

Fearn,  S.  W.,  548,  555 

Feldman,  W.M.,460 

Felkin,  486 

Fenwick,  Samuel,  72,  77 

Fenwick,  W.  Saltan,  541,  545 

Fildes,  Paul,  591 

Findel,  H.,  431,  442 

Fisher,  Irving,  618 

Fisher,  406 

Flack,  Martin,  313,  322 

Fieurens,  6 

Flint,  Austin,  44,  55,  65 

Flugge,  429 

Forbes,  J.  Graham,  567,  572 

Forlanini,  719 

Forsyth,  C.  E.  P.,  685 

Foster,  Balthazar,  117 

Foulerton,  A.  G.  R.,  394,  396,  407,  410, 

441 
Fowler,  Sir  J.  Kingston,  135,  155,  208, 

218,  221,  222,   386,  393,  470,  473, 

567,  572 
Fowler,  W.  C,  75 
Fox,  J.  C,  201 

Fox,  Wilson,  117,  373,  737,  753 
Frankel,  289 
Frankland,  283 
Franz,  Karl,  582,  591 
Freeman,  Edward  A.,  240 
Freeman,  John,  245,  268 
French,  Herbert,  201,  331,  332,  334 
Freund,  W.  A.,  274,  283,  285 
Friedrich,  422 


756 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


Gaide,  A.,  146,  156 

Gairdner,  Sir  W.  T.,  274,  285 

Galen,  420 

Gamaleia,  N.,  289,  321 

Garland,  G.  M.,  103,  117 

Garratt,  G.  C,  321 

Garre,  C,  360,  365,  366,  377,  378 

Garrod,  Sir  A.  E.,  77,  164 

Gask,  G.  E.,  162,  163,  164,  165 

Gautier,  E.,  418 

Gee,  Samuel,  24,  32,  56,  65,  84,  105, 

191,  195,  201,  22r,  274,  285 
Geissler,  H.  T.,  310,  322 
Ghon,  Anton,  471,  473 
Gilbert,  A.,  413 
Gillette,  H.  F.,  268 
Gimbert,  687,  693 
Glegg,  R.  Ashleigh,  268 
Godlee,  Sir  RickmanJ.,  128,222,231, 
240,  362,  366,  381,  384,  393,  399, 
401,  405,  408,  410,  572 
Goodall,  A.,  476,  496 
Goodall,  E.  W.,  268 
Goodbody,  F.  W.,  613,  618 
Gordon,  M.  H.,  318,  322,  429,  442 
Gordon,  W.,  449,  450,  460,  461,  652 
Goring,  C,  439,  443 
Gougerot,  413 
Gould,  Sir  A.  Pearce,  132,  362,  366, 

744,  745,  747 
Grant,  Sir  J.  Dundas,  710 

Graves,  122 

Gray,  John, 620 

Green,  Alan  B.,  569,  572 

Greenhow,  E.  H.,  274,  285,  343,  455, 

461 
Greg,  577 
Greves,  Hyla,  154 
Griffith,  A.  Stanley,  424,  441 
Grimshaw,  T.  W.,  302,  322 
Grysez,  43r,  442 
Guimbellot,  Marcel,  377,  378 
Gull,  Sir  William,  203,  221 
Gulland,  G.  L.,  476,  496 
Guyon,  F.,  240 

Haldane,  J.  S.,  5,  20,  462 

Halliburton,  W.  D.,  92 

Hallows,  Norman,  201,  331,  332,  334 

Halstead,  748 

Hamilton,  D.  J.,  180,  181,  200 

Hammond,  J.  A.,  186 

Hare,  Charles  J.,  23 

Hare,  H.  A.,  737,  753 

Harris,  J.  Delpratt,  360,  366 

Harris,  Thomas,  117 

Hartley,  P.  Horton-Smith,  84, 117, 155, 
156,  175,  221,  231,  334,  355,  357, 
393,  410,  473,  481,  484,  516,  545, 
556,  572,  592,  634,  670,  686,  724, 
753 


Hartz,  394 

Hastings,  J.,  730,  731 

Haviland,  Alfred,  450,  461 

Hedges,  C.  E.,  91,  116 

Henry,  H.  G.  M.,  ^j,  157, 160, 165 

Henshaw,  Nathaniel,  281,  285 

Hensley,  P.,  6,  20 

Heron,  442 

Heymann,  Bruno,  428,  433,  442,  443 

Hicks,  J.  A.  Braxton,  221 

Higginson,  C.  G.,  710 

Hill,  Leonard,  20,  284,  358 

Hinds,  F.,  415,  417 

Hine,  T.  G.  M.,  322 

Hippocrates,  60,  65,  133,  420,  547 

Hirt,  Ludwig,  178,  200 

Hoffmann,  F.  A.,  225,  226,  234,  240, 

280, 284 
Hogarth,  A.  H.,  634 
Holden,  G.  W.,  4x5 
Holland,  632 
Holmes,  T.,  240 
Holt,  L.  Emmett,  334 
Horder,  Sir  Thomas,  485 
Home,  W.  Jobson,  534,  535,  545 
Hort,  E.  C,  591 
Hovell,  T.  Mark,  334 
Howell,  W.  H.,20 
Huggard,  William  R.,  449,  460,  561, 

652,  670 
Hulke,  J.  W.,  240 
Humphrey,  320 
Hutchens,  H.  J.,  417 
Hutchinson,  John,  8,  11,  20,  32 
Hutchinson,  Robert,  321 

Ilkeston,  Lord,  109 

Ilott,  229 

Inman,  A.  C,  441,  584,  585,  588,  591, 

6x2,  6x3 
Irvine,  343 

Irvine,  J.  Pearson,  203,  22 x 
Israel,  James,  394,  409 
Itard,  X33, 155 

Jaccoud,  X34,  676 
Jackson,  Chevalier,  238,  240 
Jaksch,  Rudolf  von,  68,  77 
Jenner,  Sir  William,  273,  284 
Jessen,  F.,  44X 
Jessop,  Walter  H.,  572 
Johnson,  343 

Johnson,  Sir  George,  558,  562 
Johnston,  Charles  A.,  448,  460 
Jones,  D.  W.  Carmalt,  X56 
Jones,  A.  Coppen,  76,  Tj,  422 
Jones,  C.  Price,  410 
Jones,  P.  C.  Varrier,  622 
Jones,  F.  Wood,  420,  440 
Jourdanet,  D.,  449,  460 
Jousset,  Andre,  gx,  1x6 


INDEX   OF   AUTHORITIES 


757 


Kanthack,  A.  A.,  325,  326,  409 

Keith,  Arthur,  9,  11,  25,  32,  270,  284, 

345 
Kellock,  Thomas  H.,  240,  241 
Kelsch,  A.,  91,  116 
Kidd,  Percy,  231,  426,  441 
Killian,  236 
Kincaid,  390 
King,  D.  Barty,  206 
Kirkland,  Thomas,  601,  605 
Klein,  E.,  18,  21,  244,  424,  435 
Knox,  Alexander,  652 
Koch,  R.,  421,  422,  428,  578,  579,  712, 

713,718 
Kohlisch,  429,  442 
Kolmer,  John  A.,  378 
Koster,  91 
Krawkow,  569 

Laennec,  R.  T.  H.,  35,  41,  47,  49,  53, 
55,  56,  57,  58,  59,  60,  62,  65,  133, 
146,  155,  194,  195,  196,  201,  242, 
273,  285,  421,  427,  474,  528,  529, 
531,  625 

Langenbeck,  von, 394 

Latham,  P.  M.,  201 

Lebert,  H.,  201,  394,  409,  604 

Le  Damany,  91 

Lees,  David  B.,  681 

Lendon,  A.  A.,  367,  375,  378 

Levaditi,  422 

Leyden,  E.,  149,  156 

Liebermann,  L.,  6,  20 

Lillingston,  Claude,  720 

Lister,  F.  S.,  321 

Lockwood,  A.  L.,  165 

Longstaff,  G.  Blundell,  286,  320,  438, 

443 
Lord,  F.  T.,  131 
Louis,  146,  233,  625 
Lowenstein,  441 
Liibbert,  268 
Lurie,  200 
Lyell,  R.  W.,  222 
Lyster,  622 
Lytton,  Bulwer,  240 

MacAlister,  Professor,  50 

MacCormac,  Henry,  607,  618 

McCrae,  John,  339,  343 

McCrae,  Thomas,  131 

Macdonald,  W.  M.,  201 

MacDonnell,  122 

Mcintosh,  J.,  591 

Mackenzie,  H.  W.  E.,  307,  378 

Maclean,  122 

MacLeod,  I.  J.  R.,  423,  441 

Madison,  582 

Mahomed,  38,  44 

Malcolm,  W.  S.,  410 

Marcel,  660 


Martin,  Joseph  S.,  462 

Martin,  Sidney,  430 

Masson,  A.,  412,  413 

Masson,  L.,  591 

Maunsell,  S.  E.,  289,  321 

Meek,  W.  O.,  588,  591,  621,  634 

Mehu,  93 

Meltzer,  S.  J.,  358 

Melville,  342,  724 

Metchnikoff,  422 

Miller,  W.  F.,  2,  19 

Milton,  J.  Penn,  170,  175 

Moller,  424 

Moore,  Sir,  J.  W.,  302,  322 

Moore,  525 

Morgan,  W.  Parry,  720,  730 

Morland,  Egbert  C,  579 

Morris,  Sir  Malcolm,  746,  747 

Morse,  J.  Lovett,  148,  156 

Mouat,  T.  R.,  381,  384 

MUller,  I.  J.,  8,  20 

Murchison,  C,  302,  322 

Murphy,  Sir  Shirley,  454 

Musser,  John  H.,  116,  201,  225,  226, 

240,  284 
Mussy,  Gueneau  de,  88,  132 

Naegeli,  447 

Neisser,  367 

Netter,  91,  116,  119,  131,  292,  320 

Newsholme,  Sir  Arthur,  440,  443 

Nixon,  J.  A.,  165 

Obici,  Augusto,  415,  417 

Ogle,  Cyril,  383,  384 

Oliver,  Sir  Thomas,  321,  340,  341,  342, 

343 
Ophuls,  W.,  366 
Ormerod,  J.  A.,  170,  175 
Osier,  Sir  William,   87,   89,   134,  131, 

132 

Paget,   Stephen,    125,    132,    156,   366, 

378,731 
Parkes,  E.  A.,  321 
Pasteur,  321 
Pasteur,  William,  200,  334,  335,  SS'^, 

349,  350 
Paterson,   Marcus    S.,  601,   605,  609, 

610,  612,  618 
Pearson,  Karl,  438,  439,  443,  445,  446, 

457,  458,  460,  462,  625 
Pearson,  Leonard,  418 
Pearson,  S.  Vere,  720,  730 
Perls,  M.,  7,  20 
Perry,  S.  J.,  625,  626,  629,  630,  631, 

634,  635,  717,  718 
Petitjean,  G.,  703,  710 
Petri,  424 

Petrone,  Luigi  M.,  322 
Philip,  Sir  Robert,  704 


758 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


Pic,  A.,  703,  710 

Picken,  R.  M.  F.,  624,  634 

Piorry,  P.  A.,  36,  65 

Pirquet,  von,  578,  583 

Pitt,  G.  Newton,  158,  164,  203,  221 

Pohl,  W.,  380,  384 

Poirier,  P.,  19,20,  21,  85,  86,  89 

Pollock,  J.  E.,  510,  516,  625,  634 

Ponfick,  E.,  394,  409 

Poore,  G.  Vivian,  218,  222 

Pope,  E.  G.,  438,  443,  627,  628,  635 

Potain,  III 

Powell,  Sir  R.  Douglas,  20,  38,  44,  65, 
89.  117,  132, 153, 155, 156, 222, 243, 
266,  268,  277, 302, 381, 397, 405, 406, 
410,  450,  460,  473,  510,  520,  531, 
545,  553.  556, 632, 710 

Preobraschensky,  S.  S.,  238,  241 

Quain,  Sir  R.,  548,  556 

Quevli,  435 

Quincke,  H.,  360,  365,  366,  377,  378 

Rabinowitsch,  Lydia,  441 

Radcliffe,  J.  A.  D.,  468,  473,  588,  591 

Ranking,  W.  H.,  135,  155 

Ransome,  Arthur,  25,  32 

Ravaut,  92,  116 

Ravenel,  Mazyck  P.,  418,  570 

Reclus,  Paul,  365,  366 

Reeve,  Edward,  G.,  686 

Regaud,  C,  165 

Raid,  G.  Archdall,  460 

Renon,  Louis,  414,  415,  417 

Raynaud,  60,  65 

Riesman,  David,  355,  357 

Rindfleisch,    Eduard,    270,    274,    284, 

527, 531 
Ringer,  252 
Ritchie,  T.  R.,  201 
Rivers,  C.  W.,  445 
Riviere,  Clive,  119,  472,  473,  579,  721, 

730 
Roberts,  89 

Roe,  Hamilton,  109,  117 
Roentgen,  63 
Roepke,  714,  718 
Rogers,  Sir  Leonard,  675,  686 
Rokitansky,  555 
Rolland,  W.,  186,200 
Rollier,  A.,  641,  710 
Roily,  686 
Rose,  484 

Rosenbach,  Ottomer,  68,  77 
Ross,  E.  Athole,  116 
Ross,  J.  N.  MacBean,  749,  753 
Rotmann,  175 
Ruffer,  M.  A.,  419,  440 

Sabouraud,  411,  413,  416 
Sachs,  Theodore  B.,  724 


Sahli,  716 

Salter,  Hyde,  7,  9, 11,  20,  242,  245,  249, 

252,  259,  267 
Sanderson,  Sir  J.  Burdon,  11,  18,  20, 

21,  465 
Saugman,  C,  719,  721,  722,  726,  728, 

729,  730,  731 
Saxer,  F.,  418 
Schenck,  B.  R.,  411,  413 
Schmid,  449,  460,  652 
Schmorl,  429 

Scholberg,  H.  A.,  166,  167,  168,  175 
Schrotter,  von,  237 
Schulmann,  A.,  412,  413 
Schultze,  422 
Scurfield,  H.,  455,  462 
Selous,  F.  C,  650,  652 
Semon,  Sir  F.,  237 
Sharkey,  Seymour  J.,  211,  221 
Shattock,  S.  G.,  383,  384,  420 
Shaw,  H.  Batty,  380,  381,  384 
Sherrington,  C.  S.,  9 
Shore,  T.  H.  G.,  186,  200 
Shufflebotham,  343 
Sikes,  Alfred  W.,  393 
Silvius,  420 

Sitzenfrey,  Anton,  427,  442 
Skoda,  53,  103 
Slivelman,  B.,  730 
Smith,  570 

Smith,  Archibald,  449 
Smith,  Edwin,  153 
Smith,  G.  Elliott,  419,  440 
Smith,  George,  266 
Smith,  Solomon  C,  360,  365 
Smith,  Sir  Thomas,  394,  409,  744 
Smyth,  R.  Mander,  481,  496 
Solly,  S.  Edwin,  652,  670 
Solmersitz,  F.,  416,  417 
Sommerbrodt,  J.,  687,  693 
Spitta,  Harold  R.  D.,  435 
Squire,  Peter,  201 
Stadler,  E.,  625,  634 
Stansfeld,  A.  E-,  484,  485 
Steell,  Graham,  753 
Stengel,  Alfred,  357 
Steuart,  343 

Stewart,  Sir  T.  Grainger,  219,  222 
Stokes,  William,  117,  122,223,227,240 
Stone, 62 

Storks,  Robert,  730,  731 
Strangeways,  T.  S.  P.,  591 
Sturges,  Octavius,  289,  321 
Sutton,  Sir  John  Blaud-,  379,  38-4 
Swift,  J.  C,  273 
Swithinbank,  H.,  425,  441 
Szaboky,  J.  v.,  591 

Talamon,  289 
Tatham,  John,  455,  461 
Taylor,  Sir  Frederick,  62,  65 


INDEX    OF   AUTHORITIES 


759 


Taylor,  H.  H.,  397,  401,  402,  405,  410 

Thayer,  W.  S.,  117 

Thoinet,  L.,  413 

Thomas,  J.  Davies,  367,  368,  374,  377, 

378 
Thomas,  R.  Arthur,  462 
Thompson,  J.  H.  R.,  629,  630,  631,  635, 

716,  718 
Thomson,  Sir  StClair,  534,  536,  545 
Traube,  L.,  9,  20,  103,  122 
Treadgold,  H.  A.,  503,  510 
Trousseau,  A.,  62,  106,  109,  115,  117, 

212,  221,  704 
Trudeau,  716 
Tulp,  Nicholas,  69,  'jy 
Tyndall,  283 

Uhlenhuth,  574,  591 

Vaillard,  L.,  91,  116 
Vallow,  Harold,  461 
Vansteenberghe,  P.,  431,  442 
Vierordt,  Oswald,  25,  32 
Villemin,  J.  A.,  421,  441 
Virchow,  72,  387 

Waithman,  405,  406 

Waldenburg,  L.,  25,  28,  32,  275,  281, 

285 
Walker,  J.  Chandler,  245,  246,  268 
Wallis,  Mackenzie,  166,  167,  168,  174, 

175 
Walsh,  Joseph,  57o,  572 
Walsham,  Hugh,  64,  230,  430,  442,  745 
Walshe,  W.  H.,  24,  25,  32,  183,  252, 

310,  545 
Walther,  Otto,  481,  609,  614 
Ward,  Ernest,  438,  443 
Washbourne,  J.  W.,  50,  65 
Watson,  157 
Watt,  343 
Weber,  F.  Parkes,  320,  451,  461,  605, 

651 
Weber,  Sir  Hermann,  285,  437,  443, 
605,  638,  651,  652 


Weir,  H.  B.,  591 

Weist,  J,  R.,  238,  240 

Welch,  287,  320 

Welch,  W.H.,  356,  358 

Wells,  John  W.,  674,  685 

West,  Samuel,  155,  156,  171,  i75,  321, 

323,  334,  407,  410 
Wethered,  F.  J.,  285,  494 
Wheaton,  S.  W.,  418 
White,  P.  Bruce,  201 
Whitla,  Sir  William,  343 
Whitlick,  744 
Widal,  92,  116 
Wild,  R.B.,  410 
Wijeyeratne,  434 
Wilks,  Sir  Samuel,  550 
Willcox,  W.  H.,  260,  268,  315,  322 
Williams,  C.  J.  B.,  46,  59,  243,  268,  445, 

460,  674,  685 
Williams,  C.  Theodore,  222,  281,  285, 

435,  436,  443, 445,  460,  625,  639,  652, 

654,  666,  670,  674,  685 
Williams,  Dawson,  441 
Williams,  G.  E.  O.,  380,  381,  384 
Williams,,  Leonard,  355,  357 
Williams,  Owen  T.,  685 
Williams,  P.  Watson,  8,  20,  237,  243, 

268 
Williams,  Stenhouse,  424,  441 
Williamson,  K.  D.,  165 
Wilms,  220,  729 

Wilson,  J.  A.,  201,  331,  332,  334 
Woillez,  E.  J.,  24,  32 
Wollstein,  Martha,  324,  334 
Wood,  E.  B.,  442 
Worrall,  G.S.,  156 

Wright,  Sir  Almroth,  320,  57i,  583,  59i 
Wynn,  W.  H.,  410 

Xylander,  574,  59 1 

Yeo,  Burney,  605,  680 
Young,  R.  A.,  173,  174,  232 

Zapelloni,  L.  C,  378 


INDEX 


Aberdeen,  Medical  Of&cer  of  Health, 
overcrowding  and  phthisis,  455 

Abrahams,  A.,  Hallows,  Norman,  and 
French,  Herbert,  estimate  of  the  fre- 
quency of  pulmonar}'  complications 
in  influenza  epidemic,  331;  "helio- 
trope cyanosis  "  in  influenzal  pneu- 
monia, 332;  mortality  in  influenza 
epidemics,  332 

Abrams,  Albert,  "  the  lung  reflex  of 
contraction,"  349 

Abscess  of  liver,  tropical,  character- 
istic expectoration  in,  68 

Abscess  of  lung:  causes  of,  359;  foreign 
bodies  in  air-passages  and,  235; 
haemoptysis  in,  555;  in  broncho- 
pneumonia, 326;  in  intrathoracic 
growth,  359;  in  pneumonia,  305, 
306,  307;  in  phthisis  (the  caseous 
abscess),  524;  physical  signs, 
360;  symptoms,  359;  treatment, 
medicinal,  360;  — -,  surgical,  360; 
steps  in  the  operation,  361 ;  results, 
360;  tuberculous  or  caseous,  524 

Abscess  of  mediastinum,  734  {see  also 
Mediastinitis,  suppurative);  of  rib, 
tuberculous,  83 

Acid-fast  bacilli,  423,  424;  in  gangrene 
of  lung,  364 

Ackland,  T.  D.,  causes  or  antecedent 
conditions  in  forty  cases  of  bronchi- 
ectasis, 208 

Actinom3?cosis,  394 ;  see  Streptotrichosis 

Addison,  Thomas,  anatomy  of  the 
lung,  I,  2;  inflammatory  process  in 
pulmonary  tuberculosis,  466 

Adenoid  growths  and  chest  troubles, 
177;  reflex  exciting  cause  of  asthma, 
246 

Adirondack  Cottage  Sanitarium,  tables 
showing  condition  of  patients,  627, 
628 

Adler,  I.,  primary  carcinoma  of  lung, 

751 
Adrenalin   chloride   spray   in   asthma, 

259;  contra-indicated  in  haemoptysis, 

705 
Adventitious  matters  in  sputum,  76 


Adventitious  sounds:  definition  and 
common  significance,  41;  inter- 
national nomenclature,  45 ;  mode  of 
formation  of,  56;  see  Rales 

jEgophony,  definition  and  common 
significance,  43;  in  broncho-pneu- 
monia, 329;  in  haemothorax,  159;  in 
pleural  efiusion,  61,  102;  over  con- 
solidated lung,  61,  62,  102;  theory 
of  production  of,  61,  62 

^rotherapeutics  in  emphysema,  281 

etiology  of  pulmonary  tuberculosis, 
419-462  ;  see  Pulmonary  tuber- 
culosis, (ztiology 

African  Highlands,  South,  climate  and 
description  of,  642-650;  for  phthisi- 
cal patients,  641,  644-647,  691; 
immigration  laws  as  to  admission  of 
tuberculous  patients,  636 

Agglutination  test  in  phthisis,  589 

Aix-la-Chapelle  for  piilmonary  syphilis, 
392 

Aix-les-Bains  for  catarrhal  asthma , 
256;  summer  health  resort,  669 

Alar  chest,  79 

Alassio,  winter  health  resort,  663 

Albuminous  or  serous  expectoration: 
in  acute  pulmonary  oedema,  353, 
354;  following  paracentesis  of  chest, 
114 

Albuminuria  and  liability  to  pneu- 
monia, 287;  complicating  phthisis, 
569;  in  fibroid  phthisis,  520,  569; 
in  influenza  pneumonia,  332;  unsuit- 
able for  high  climates,  640 

Alcohol  as  cardiac  stimulant  {see 
Individual  diseases);  injections  into 
superior  laryngeal  nerve  in  tuber- 
culosis of  the  larynx,  700 

Alcoholism  and  abscess  of  the  lung, 
359;  and  bronchitis,  177;  and  de- 
layed resolution  in  pneumonia,  305 ; 
and  fibroid  changes  in  the  lung,  336; 
and  liability  to  pneumonia,  287; 
haemoptysis  in,  549 

Alexander,  Dr.  John,  researches  on 
respiratory  and  alimentary  infection 
in  tuberciilosis,  431 


760 


INDEX 


761 


Algeciras  as  winter  resort,  663;  climate 
of,  643,  664;  for  asthma,  256 

Algiers  as  winter  resort  for  asthma, 
256,  664;  for  chronic  bronchitis,  664; 
for  quiescent  phthisis,  664;  unsuit- 
able in  late  spring,  669 

Alimentary  canal,  tuberculosis  infec- 
tion conveyed  through,  430,  431 

Aliwal  North,  South  Africa,  for 
phthisis,  645  ;  sulphur  springs,  646 

AUard  and  Koster  on  tuberculous 
pleurisy,  91 

Allevard  -  les  -  Bains  for  catarrhal 
asthma,  256;  summer  health  resort, 
669 

Alpine  altitudes  after  pleurisy,  108; 
for  treatment  of  phthisis,  283,  637- 
641 ;  for  treatment  of  surgical  tuber- 
culosis, 641 

Alveolar  cells  in  sputum,  71 

Alveoli,  pulmonary,  3,  50 

Amersham,  suitable  locality  for  per- 
manent residence,  669 

Amoeba  of  dysentery  in  tropical 
abscess  of  the  liver,  68,  69 

Amphoric  breathing,  41,  45,  55 

Amphoric  or  metallic  echo,  43,  62 

Amyl  nitrite  in  haemoptysis,  703,  706 

Anaemia  and  false  or  spurious  haemop- 
tysis, 560;  of  larynx  in  laryngeal 
tuberculosis,  534 

Anaerobic  organisms  in  haemothorax, 
160;  in  foetid  empyema,  123 

Anaesthesin  in  laryngeal  tuberculosis 
700 

Anaesthetic,  choice  of,  in  surgical 
operations  in  cases  of  chest  disease, 
128;  broncho-pneumonia  resulting 
from,  324 

Analogy  between  asthma  and  vaso- 
motory  angina,  243 

Anaphylaxis  in  asthma,  245  ;  in  serum 
treatment  of  pneumonia,  319;  in 
tuberculin  treatment,  714 

Anatomy  of  bronchi,  2,  3;  of  lungs, 
I,  2 

Andes,  South  American,  in  treatment 
of  phthisis,  642 

Andrew,  Dr.  J.,  ergot  in  haemoptysis, 
705 

Aneurism:  aortic,  rupturing  into  pleura 
cause  of  haemothorax,  157;  com- 
pression by,  causing  narrowing  of 
bronchi,  202,  203;  —  pulmonary 
gangrene,  364;  simulated  by  em- 
pyema pulsans,  122;  — -  simulating 
mediastinal  tumour,  747;  — •  points 
of  distinction  between,  748,  749; 
pulmonary,  cause  of  hemoptysis  in 
bronchiectasis,  213;  — ,  in  pulmonary 
tuberculosis,     548;     — ,    mode     of 


formation,  site  of,  548;  — ,  present- 
ing through  walls  of  bronchus,  549 

Anthoxanthum  odoratum,  pollen  caus- 
ing hay  asthma,  248 

Anthracosis  due  to  inhalation  of  coal- 
dust,  338;  pulmonary,  an  inhala- 
tion infection,  431 

Antiformin  method  for  finding  tubercle 
bacilli,  574 

Antimony  wine  in  bronchitis,  188 

Antiphlogistine  in  pneumonia,  312;  in 
purulent  bronchitis,  188;  in  sero- 
fibrinous pleurisy,  107 

Antipneumococcic  serum  in  pneumonia, 
318 

Antipyretics  in  the  treatment  of 
phthisis,  679;  • —  of  influenzal 
pneumonia,  333 

Antiseptic  inhalations  in  treatment  of 
bronchiectasis,  218;  in  phthisis,  680, 
681 ;  in  laryngeal  tuberculosis,  698 

Aphonia  in  subacute  tuberculosis  of 
lungs,  499 

Aphthous  condition  of  mouth  and 
throat  in  advanced  phthisis,  treat- 
ment of,  701 

Apomorphine  in  acute  bronchitis,  189; 
in  asthma,  258,  261 

Aponeurotic  rheumatism,  80,  81 

Arcachon  as  spring  health  resort,  669; 
for  asthma  and  phthisis,  256,  663 

Arequipa  (Peru)  for  asthma,  256 

Aretaeus,  description  of  phthisical 
chest,  79;  description  of  case  of 
advanced  tuberculosis,  573;  on 
pleurisy,  86 

Argentine,  hydatid  disease  of  the  lungs 
in,  367;  La  Cumbre  district,  suitable 
for  consumptives,  650 

Arkle,  C.  J.,  and  Hinds,  F.,  on  asper- 
gillosis, 415 

Arloing,  Professor,  agglutination  test, 

589 

Arneth's  blood  picture  in  phthisis,  503, 
504 

Aron  and  Hutchinson,  residual  tension 
of  the  lungs,  8 

Arosa  for  asthma,  256;  for  phthisis, 
637;  mean  winter  climatology  of, 
642,  643 

Arrest  of  pulmonary  tuberculosis  of 
many  years'  duration,  with  illus- 
trative cases,  in  acute  pneumonic 
phthisis,  481;  in  chronic  pulmonary 
tuberculosis,  632-634;  in  fibroid 
phthisis,  516-519;  see  also  Sana- 
torium treatment,  results  of 

Arsenic  in  asthma,  258,  263;  in  asper- 
gillosis, 417;  in  emphysema,  280; 
in  febrile  cases  of  phthisis,  677,  732; 
in  pneumonia,  317 


762 


DISEASES   OF   THE    LUNGS   AND    PLEURA 


Arterial  supply  of  bronchi,  2,  3 

Arterio-sclerosis  and  acute  pulmonary 
oedema,  355 

Arthritis  and  pneumonia,  306,  307, 
309 

Artificial  pneumothorax :  apparatus  for 
performing,  720;  cases  suitable  for, 
680,  707,  725,  726;  complications 
occurring  during  treatment,  723;  - — , 
gas  embolism,  723;  — ,  perforation  or 
rupture  of  lung,  with  illustrative 
case,  724 ;  — ,  pleural  reflex  or  pleural 
shock,  722;  — ,  pleurisy,  723;  dura- 
tion of  treatment,  723;  results  of 
treatment  at  Berks  and  Bucks 
Sanatorium,  727;  risks  attending 
treatment,  722;  technique,  720 

Ascarus  lumhricoides  in  air-passages, 
,225 

Aspergillosis,  414;  diagnosis,  416; 
identification  of  parasite,  416;  illus- 
trative case,  415;  primary  and 
secondary  forms,  414;  symptoms, 
415;  treatment,  417 

Aspergillus  fumigatus,  414-416;  ex- 
perimental inoculation  of,  428  ; 
nidulans,  415 

Aspiration,  in;  see  Paracentesis 

Ass's  milk  in  pulmonarj'  tuberculosis, 
603 

Assuan  for  bronchitis,  193;  for  quies- 
cent phthisis  in  winter,  665 

Asthma,  242;  cstiology,  244;  age  and  sex 
incidence,  245 ;  animals,  246 ;  — ,  rela- 
tion to  cats,  246 ;  — ,  horses,  246 ;  due 
to  spasm  of  muscles  of  bronchioles, 
242;  exciting  causes  of  the  attack, 
245-247;  — ,  anaphylactic  origin  of, 
in  some  cases,  245 ;  due  to  hyper- 
sensitiveness  to  foreign  protein 
emanating  from  animals,  bacteria, 
or  plants,  246;  — -,  dust  inhalation, 
247,  248;  illustrative  case  due  to 
rosewood  dust,  264;  • — ,  emotional 
causes,  247;  — ,  inherited  predis- 
position, 244;  — ,  reflex  irritation, 
246;  from  alimentary  tract,  247; 
from  bronchial  tract,  with  illus- 
trative case,  266;  from  nose,  246; 
from  uterine  region,  247;  blood, 
eosinophilia  in,  during  attacks,  252; 
bronchial  casts  in,  252;  — ,  with 
illustrative  case,  266;  clinical  varie- 
ties of,  247;  — ,  animal  asthma,  245, 
246;  — ,  bronchitic  or  catarrhal,  248, 
266;  — ,  cardiac,  250;  • — ,  dust,  248; 
with  illustrative  case  due  to  rose- 
wood dust,  264;  — ,  gouty,  245,  249; 
— ,hay,  246;  "  autumnal  catarrh"  in 
America,  249;  from  pollen  of 
Anthoxanthum  odoratum  and  other 


plants,  248;  relation  to  hay  fever, 
248;  treatment,  262;  local,  262;  by, 
"  Pollacine,"  262 ;  by  pollantin,  262 ; 
sea-voyages  in,  263;  ■ — ,  horse,  246; 
— ,  nasal,  249;  — ,  peptic,  249;  — , 
spasmodic  (idiopathic  or  essential),, 
247;  — ,  ursemic,  250;  eczema,  urti- 
caria, and,  245;  emphysema  and, 
242,  248,  253;  food-proteins  and, 
245;  hjemoptysis  in,  253;  heredity 
and,  244;  influenza  and,  245;  inter- 
changeability  of  vaso-motor  angina, 
menopausal  sweatings,  and,  247; 
menopause  and,  245;  pathology,  242; 
— ,  absence  of  distinctive  morbid 
changes,  242;  — ,  Curschmann's 
"  bronchiolitis  exudativa,"  242;  — , 
theory  of  vascular  turgescence  of 
bronchial  mucous  membrane,  242; 
periodicity  of  attacks,  253;  physical 
signs  in,  252;  prognosis,  254;  sputum, 
252;  — ,  appearance  of  Cursch- 
mann's spirals  in,  252;  — ,  eosino- 
philia in,  252;  — ,  Leyden's  crystals 
in,  252;  symptomatology,  250;  — , 
characteristic  physiognomy  of 
patient,  250;  — ,  description  of  the 
attack,  250;  treatment,  (i)  general: 
climatic,  255;  dietetic,  257;  medi- 
cated airs  and  baths,  256;  medi- 
cinal, 258;  of  digestive  functions, 
257;  of  nose,  258;  of  other  sources 
of  peripheral  irritation,  258 ;  specific, 
255;  vaccines,  255,  263;  (2)  of  hay 
asthma,  262,  263;  (3)  of  the  par- 
oxysm, 258:  "asthma-cures,"  259, 
260;  medicinal,  258;  powders  for 
burning,  259 

Atelectasis  pulmonum  and  bronchiec- 
tasis, 210, 211 

Atheroma  and  haamoptysis,  546 

Atomiser,  699 

Atropine  in  acute  pulmonary  oedema, 
356;  in  asthma,  243,  261 

Auenbrugger,  percussion  first  used  by, 

35 

Aural  tuberculosis,  539 

Auscultation:  combination  of  methods 
of  percussion  and,  63;  definition  and 
significance  of  sounds  heard  by,  39, 
40;  immediate  and  mediate,  47; 
international  nomenclature,  44;  not 
wholly  unknown  to  ancient  Greeks, 
47;  theory  of,  48 

Auscultatory  percussion  bell  sound, 
62;  use  of  method  for  defining  out- 
lines of  organs  untrustworthy,  63 

Australia,  hydatid  disease  of  lungs  in, 
376;  sea- voyages  to,  restrictions  as 
to  landing  of  tuberculous  patients, 
636,  656 


INDEX 


I^Z 


Autumn,  climatic  treatment  of  phthisis 

in, 653 
"  Autumnal  catarrh,"  249 
Avian  tuberculosis,  426 

Babes  and  Levaditi  on  streptothrix 
nature  of  the  tubercle  bacillus,  422 

Baccelli,  Professor,  pectoriloquie  apho- 
nique,  102,  120 

Bacillus :  coli  in  gangrene  of  the 
lung,  364;  —  in  foetid  empyema, 
123;  Friedlander,  in  broncho-pneu- 
monia, 325;  — in  lobar  pneumonia, 
290;  of  leprosy,  423;  perfringens 
in  septic  haemothorax,  160;  PfeiiJer, 
in  bronchitis,  179;  — ,  in  influenzal 
pneumonia,  331,  332;  — ,  in  lobar 
pneumonia,  290;  — ,  in  purulent 
bronchitis,  187;  — ,  in  septic  haemo- 
thorax, 160;  proteus  vulgaris  in 
gangrene  of  the  lung,  364;  pyo- 
cyaneus  in  bronchitis,  179;  —  in 
gangrene  of  the  lung,  364;  tuber- 
culosis, 421 ;  see  Tubercle  bacillus 

Badenweiler,  Black  Forest,  health 
resort  for  phthisis,  651 

Bagshot  for  asthma,  255 

Ballin,  experimental  inoculation  of 
A  spergillus  fumigatus  ,428 

Bandelier  and  Roepke,  scheme  of 
tuberculin  dosage,  714-716 

Bardswell,  Noel,  diet  at  King  Edward 
VII.  Sanatorium,  615;  results  of 
treatment  at  the  Mundesley  Sana- 
torium, 616 

Bardswell  and  Chapman,  J.  E.,  diet 
for  phthisical  patients,  614;  —  and 
Goodbody,  F.  W.,  metabolism  in 
phthisis,  613 

Bardswell  and  Thompson,  J.  H.  R., 
results  of  sanatorium  treatment  at 
the  King  Edward  VII.  Sanatorium, 
629;  results  of  tuberculin  treatment 
as  practised  at  the  King  Edward  VII. 
Sanatorium,  716,  717 

Barkly  East,  South  Africa,  for  phthisis, 
646 

Barr,  Sir  James,  lung  reflex  contrac- 
tions and  contralateral  collapse,  350; 
use  of  adrenalin  chloride  in  chronic 
sero-fibrinous  effusions,  115 

Barrs,  A.  G.,  on  tuberculous  nature 
of  acute  sero-fibrinous  pleurisy,  91 

Bartolet  on  chylothorax,  167 

Basal  phthisis,  470;  diagnosis  from 
bronchiectasis,  216 

Bashford,  E.  F.,  Bradford,  Sir  J. 
Rose,  and  Wilson,  J.  A.,  filter-pass- 
ing virus  in  influenza,  187,  331,  332 

Bath:  compressed  air  at  Brompton 
Hospital  in    treatment  of   asthma, 


257;  — ,  in  treatment  of  emphysema, 
281,  282;  tepid  and  cool,  to  reduce 
pyrexia  in  broncho-pneumonia,  330; 
— ,  in  pneumonia,  311,  312 
Baumgarten,    congenital    infection    in 

tuberculosis,  427 
Baxter  on  chest  measurements,  24,  27 
Bayard,  Campbell,  statistics  on  English 

climatology,  176 
Bayle,    the    "  tubercular  nodule "    of 

phthisis,  420 
Beau  on  the  vesicular  murmur,  49 
Beaufort    West,     South     Africa,     for 

phthisis,  644 
Beaulieu,    Riviera,   for  phthisis,    662 ; 

spring  health  resort,  668 
Beck,  Max,  on  reaction  to  the  tuber- 
culin test,  582 
Bed  of  consumptive  patient,  599 
Beef-tea,  how  to  make,  330 
Beevor,     Sir     Hugh,     prevalence     of 

phthisis  in  Norfolk,  436,  437 
Behring,  von,  alimentary  infectioa  in 

phthisis,  431 
Belfast,    Transvaal,     sanatorium     for 

phthisis,  644 
Belladonna  in  broncho-pneumonia,  330 
Bell's    Liquor    Picis    Aromaticus    for 
secreting   cavities,    690;    in   chronic 
bronchitis,  192 
Bell-sound  [Bruit  (Vairain),  43,  44;  in 
■  pneumothorax,    62;    in    subphrenic 
abscess,   63;    over  pulmonary  cavi- 
ties, 63 
Bendigo,     New     South     Wales,     for 

phthisis,  657 
Benger's  food  in  acute  ulceration  of 

bowel,  695 
Bennett,  Hughes,  and  Williams,  C.  J. 

B.,  cod-liver  oil  in  phthisis,  674 
Ben  Rhydding  for  asthma,  256 
Beraneck's  tuberculin,  714 
Bert,    Paul,    experiments    on    elastic 
pressure  of  lungs  and  expansion  of 
chest  wall,  9 
Besredka  method  of  vaccine  treatment, 

320 
Bethlehem,    Orange    Free    State,    for 

phthisis,  649 
Bettmann,   M.,  on  plastic  bronchitis, 

197 
Beurmann,  de,  on  sporotrichosis,  411, 

413 
Biach,  aetiology  of  pneumothorax,  134 
Biarritz,    autumn    and    winter    health 

resort  for  phthisis,  664 
Biermann  on  plastic  bronchitis,  197 
Birch-Hirschfeld,     observations     sup- 
porting  the  view  that    infection    in 
phthisis    is   by    inhalation,    not    in- 
gestion, 429 


764 


DISEASES    OF   THE   LUNGS   AND    PLEURA 


Birds,  tuberculosis  in,  426 
Black  Forest  for  phthisis,  651 
Blarney  for  chronic  bronchitis,  193 
Bleeding;  see  Venesection 
Blisters;  see  Counter-irritation 
Bloemfontein,  Orange  Free  State,  for 

phthisis,  674 
Blood-changes:    in    acute   pneumonic 
phthisis,  476;    in  asthma,   254;    in 
bronchiectasis,  216;  in  chronic  pul- 
monary  tuberculosis,    503;    in   em- 
pyema,  121;  in  hydatid  disease  of 
lungs,    369,    370;    in   pleurisy   with 
effusion,    121;    in   pneumonia,    298, 
299,  476;  in  tuberculous  meningitis, 
567 
Blood-pressure:  in  phthisis,  504,  548; 
high    tension    in    acute    pulmonary 
oedema,  355 
Blood-vessels  of  the  lungs,  4,  5 
Blue  Mountains,  Australia,  for  phthisis, 

657 

Bodington,  George,  in  1840  fore- 
shadowed sanatorium  treatment, 
607 

Bogota,  South  American  Andes,  for 
phthisis,  642 

Bollinger,  parasite  of  streptotrichosis, 

394 

Bondet  and  Chauveau,  observations  on 
the  production  of  the  vesicular 
murmur  and  bronchial  breath- 
sound,  50,  54 

Bone  and  joint  tuberculosis,  propor- 
tion due  to  bovine  infection,  433 

Bordighera,  Riviera,  as  spring  health 
resort  for  phthisis,  658 

Boshof,  Orange  Free  State,  climate  of, 
648 

Botzen  for  grape  cure,  604 

Bouchard,  C.  H.,  and  Gimbert, 
creosote  and  guaiacol  in  phthisis, 
687 

Bournemouth  for  asthma,  256,  659; 
for  bronchitis,  193,  659;  for  delicate 
children,  594;  mean  winter  tem- 
perature, 659;  phthisis  in  autumn, 
winter,  spring,  654,  658,  668 

Bovine  tuberculosis,  425;  danger  from 
infected  milk,  431;  infection  from, 
causing  bone  and  joint  tuberculosis, 
433;  — ,  tuberculosis  of  mesenteric 
glands,  433;  — ,  tuberculous  peri- 
tonitis, 433;  — ,  ulceration  of  the 
bowel,  433;  see  also  Perlsucht 

Bowditch,  H.  I.,  dampness  of  the  soil 
and  phthisis,  450;  paracentesis 
thoracis,  109 
Bowel,  acute  ulceration  of,  694;  diet 
in,  695;  drugs  in,  695,  696;  treat- 
ment, 696;  — ,  chronic  ulceration  of, 


696;  drugs  in,  696,  697;  treatment 
and  diet,  696,  697 
Bradford,   overcrowding  and  phthisis 

in,  455 

Bradford,  Sir  John  Rose,  on  haemo- 
thorax,  159;  on  massive  collapse  of 
the  lung,  347,  349;  on  purulent 
bronchitis,  187;  — ,  Bashford,  E.  E., 
and  Wilson,  J.  A.,  on  filter-passing 
virus  in  influenza,  187,  331,  332 

Braemar  for  asthma,  257 

Brandy  in  acute  ulceration  of  bowel, 
695;  in  broncho-pneumonia,  330; 
in  influenzal  pneumonia,  334;  in 
pneumonia,  316;  in  streptotrichosis, 
409 

Brauer,  Professor,  artificial  pneumo- 
thorax, 719 

Breathing;  see  Breath-sounds 

Breathing  exercises  and  after-treat- 
ment of  empyema,  129 

Breath-sounds,  definition  and  signi- 
ficance of,  39-41;  international 
nomenclature,  44,  45;  mechanism  of 
production  and  disease-association 
of,  48-56;  varieties  of :  abnormal,  51; 
amphoric,  41,  45,  55;  blowing,  40; 
bronchial,  40,  53,  54;  broncho- 
vesicular,  40,  53;  cavernous,  41,  45, 
55;  cog-wheeled,  40,  45,  52;  com- 
pensatory, 40,  44,  52;  diminished, 
44;  exaggerated,  40,  44,  51;  harsh, 
coarse,  subtubular,  40,  53;  inter- 
rupted inspiration,  40,  45;  indeter- 
minate, 53;  jerking,  40,  45,  52; 
normal  vesicular  murmur,  40,  49; 
partial  suppression  of,  40;  prolonged 
expiration,  40,  44,  52;  puerile,  40, 
44,  51;  suppressed,  40,  44,  51; 
tracheal,  40;  transitional,  53;  tubu- 
lar, 40,  45,  54;  vesicular,  40,  49; 
vesico-tubular,  45,  53;  wavy,  40,  45, 
52;  wavy  cavernous,  52;  weak,  40, 

44,  51 
Brehmer,  introduction  of  sanatorium 

treatment  for  phthisis,  607 
Brickdale,  Fortescue,  on  haemothorax, 

161 
Bridge  of  Allan  for  bronchitis,   193; 

spring  health  resort,  668 
Brighton  for  phthisis  in  autumn,  654 
Bright's  disease  and  bronchitis,   177; 

and  pleurisy,   90;   and  pneumonia, 

287, 309 
Bristowe,  J.  S.,  on  theory  of  percussion, 

46 
Broadstairs  for  delicate  children,  594; 

for  phthisis  in  autumn,  654 
Brodie,    Sir    Benjamin,    removal    of 

foreign    body    by     inversion     and 

tracheotomy,  239 


INDEX 


765 


Brodie,  T.  G.,  and  Dixon,  W.  E., 
bronchial  spasm  as  cause  of  asthma, 
244;  effect  of  adrenalin  in  haemopty- 
sis, 705;  experiments  with  drugs  in 
asthma,  243 

Brompton  Hospital  for  Consumption: 
cases  of  streptotrichosis  at,  407; 
compressed-air  baths  at,  257,  282; 
first  medical  report,  family  history 
of  phthisis,  445 ;  frequency  of  occur- 
rence ,  of  lardaceous  disease  in 
phthisis,  based  on  autopsies  at,  567, 
568;  health  of  staff  and  risk  of 
acquiring  phthisis  at,  435;  methods 
of  dealing  with  sputum  at,  600,  601; 
mortality  statistics  at,  625 ;  observa- 
tions on  the  opsonic  index  of 
phthisical  patients  at,  585-587;  per- 
centage of  cases  of  tuberculous 
pneumothorax  at,  137;  relative 
frequency  of  more  important  com- 
plications of  phthisis  at,  532;  statis- 
tics of  age-incidence  and  of  causes 
of  bronchiectasis  from,  206,  208 

Brompton  Hospital  Sanatorium, 
Frimley:  graduated  labour  at,  609; 
non-infectivity  of  telephone  mouth- 
piece used  by  patients  at,  435 

Bronchi,  anatomy  of,  2,  3;  dilatation 
of,  206  (see  Bronchiectasis);  general 
arrangement  of ,  2 ;  narrowing  of,  202 ; 
— ,  causes  of,  localised  or  general, 
202;  — ,  cicatricial  ulcerative  con- 
traction and,  202;  — ,  invasion  of 
bronchus  by  malignant  growth,  202 ; 
— ,  pressure  by  malignant  growths, 
or  aneurism,  202,  203,  205;  — , 
symptoms  and  signs  of,  202 ;  — , 
syphilitic  ulceration  and,  202,  205; 
— ,  treatment,  205 

Bronchial  breathing,  40,  53,  54  {see 
Breath-sounds,  bronchial);  casts,  69; 

—  in  asthma,  265 ;  —  in  diphtheria, 
69;  —  in  pneumonia,  69;  —  in 
plastic  bronchitis,  196;  catarrh  and 
influenza,  331;  —  and  pneumonia, 
295  [see  Bronchitis);  contraction  and 
massive  collapse  of  lung,  349 ;  glands, 
tuberculosis  of,  471,  472;  spasm  and 
asthmatic  attack,  244 

Bronchiectasis,  206;  (etiology,  208; 
resulting  from  atelectasis  pulmonum 
(congenital   collapse  of  lung),  210; 

—  bronchial  stenosis,  208,  209;  — 
chronic  bronchitis,  209 ;  —  fibrosis  of 
lung,  whether  of  pulmonary  or  pleural 
origin,  210;  —  foreign  body  in 
bronchus,  209,  216  {see  also  Chapter 
XIV.,  with  illustrative  case,  229); 
age-incidence  in,  206;  anatomy, 
morbid,    of,   206;    — ,  area  of  lung 


affected  in,  207;  -— ,  destructive  ex- 
cavation of  lung  in,  207,  211,  215; 
— ,  gangrene  of  lung  in,  211;  — , 
varieties  of:  "cylindrical"  and 
"saccular,"  206,  207;  cerebral  ab- 
scess in,  2x3;  clubbing  of  fingers 
and  toes  in,  213;  death  in,  from 
cerebral  abscess,  213;  — ,  from  septic 
broncho-pneumonia,  213;  diagnosis, 
216;  — ,  from  basal  phthisis,  216; 
— ,  itom  localised  empyema,  216; 
Dittrich's  plugs  in,  212;  duration  of 
disease,  215;  general  health  long 
remaining  good  in ,  2 1 2 ,  2 1 3 ;  physical 
signs  in,  214,  215;  pulmonary  osteo- 
arthropathy in,  213;  sputum  in, 
characteristic  manner  of  expectora- 
tion of,  212;  — ,  large  in  amount, 
212;  — ,  offensive  in  character,  212; 
— ,  resolving  on  standing  into  three 
layers,  212;  symptoms,  211-214; 
"  veiled  puff  "  of  Skoda,  215;  treat- 
ment, 217;  — ,  antiseptic  inhalations 
in,  218;  — ,  creosote  vapour  baths 
in,  2x7;  — ,  internal  administration 
of  drugs,  218;  — ,  intratracheal 
injections,  219;  — ,  postural  evacua- 
tion of  cavity-contents,  218;  — , 
removal  of  foreign  body  from 
bronchus,  217;  — ,  surgical:  draining 
of  cavities,  219;  thoracoplasty,  220; 
Wilms'  operation  of  "  rib  mobilisa- 
tion," 220 

Bronchiolectasis  (acute  bronchiec- 
tasis), 211;  following  acute  bron- 
chitis in  young  children,  211;  the 
honeycomb  lung,  211 

Bronchitis  (bronchial  catarrh),  176; 
aetiology,  176;  — ,  after  surgical 
operations,  179;  anatomy,  morbid, 
of,  180;  bacteriology  of,  179;  classi- 
fication and  clinical  varieties  of,  i8r; 
— ,  acute  asthenic  bronchitis,  184; 
with  illustrative  case,  185;  — ,  acute 
tracheo-bronchitis,  181;  signs  and 
symptoms,  182;  — ,  capillary  bron- 
chitis (suffocative  catarrh),  182; 
diagnosis,  signs,  and  symptoms,  183, 
184;  — ,  catarrhe  sec  (bronchitis 
sicca),  195 :  sputa  margaritacea, 
pearly  sputum,  196;  • — ,  chronic 
(chronic  muco-purulent  catarrh), 
190;  signs  and  symptoms,  191,  192; 
— ,  pituitous  catarrh  (bronchorrhoea 
serosa),  194;  sputum  resembling 
"  serous  expectoration,"  but  not 
albuminous,  194;  illustrative  case, 
195;  — ,  plastic  bronchitis,  196; 
aetiology,  197;  appearance  and  nature 
of  casts,  196;  physical  signs  and 
symptoms,  198;  treatment,  200;  — , 


766 


DISEASES   OF  THE    LUNGS   AND   PLEURA 


purulent  bronchitis,  i86,  191;  bac- 
teriology of,  187;  chronic  form,  191; 
epidermic  form  among  troops,  186; 
— ,  putrid  and  foetid  bronchitis,  192 ; 
prognosis    in    acute,    187;    treatment 
of  acute,  188-190;  of  chronic,  192; 
climatic,    193;    medicinal,    192;    of 
plastic,  200 
Broncho-blenorrhoea,  187,  191 
Broncho-mycosis,  180 
Bronchophony,   definition  and  signifi- 
cance,    43;      international    nomen- 
clature, 45;  method  of  production, 
61 
Broncho-pneumonia      (lobular     pneu- 
monia): cztiology,  323-324;  — ,  acrid 
vapours,  324 ;  — -,  after  surgical  opera- 
tions, 324;    — ,  aspiration  of  food, 
324;  — ,  bronchitis,  323;  — ■,  hsemop- 
tysis,    551;   — ,  infectious   diseases, 
323;  — ,  influenza,  331;  — ,  phthisis, 
323;  — ,  poison  gases,  324;  — ,  ana-    ! 
tomy,  morbid,  of,  325;  — ,  forma-    j 
tion  of  abscesses  in  lung  in  cases  of   i 
septic  origin,  326,  359;  bacteriology,    | 
324;  — .  homologous,  heterologous, 
and  mixed  infection  in,  325;  micro- 
scopical appearances,  326;    varieties   j 
of:   primary,   323,   327;   resembling 
lobar  pneumonia,  327 ;  — ,  secondary, 
323 J  327;  confluent  and  disseminated 
forms,    with    respective    signs    and 
symptoms,     327-329;     pseudo-lobar 
type,     328;     tendency    to    delayed 
resolution   of   lung,   and   formation 
of     pulmonary     fibrosis,     329;     — , 
treatment,    329;    see   also  Influenzal 
pneumonia,  331-334 
Bronchorrhoea     serosa     {see    Catarrh, 

pituitous,)  194 
Bronchoscopy  in  bronchiectasis,  217; 
diagnosing    foreign    bodies    in    air- 
passages,  209,  236;  for  removal  of 
foreign  bodies  in  bronchi,  209,  238 
Broncho-spirochsetosis,  180 
Brown,    A.    Samler,    Guide   to   South 

Africa,  644 
Brown,   Langdon,   effect  of  adrenalin 

on  blood-supply  of  lungs,  705 
Brown,  Lawrason,  after-history  results 
of  patients  at  Adirondack  Cottage 
Sanitarium,  627 
Browne,    Sir    J.    Crichton-,    selective 
growth  characteristics  of  vegetable 
organisms,  447 
Brownlee,  Dr.,  the  fall  in  the  death- 
rate   from    tuberculosis    at    varying 
ages  and  in  different  localities,  436, 
453;  exposure  to  wind  and  phthisis, 
450;  types  or  varieties  of  phthisis: 
the  middle. age  type,  453,  458;  the 


old-age  type,  453;  the  young  adult 
type,  450,  453,  458;  on  the  epi- 
demiology of  phthisis  in  Great 
Britain  and  Ireland,  457,  458; 
relation  of  various  occupations  to 
phthisis,  455 ;  report  on  phthisis 
death-rates,  436,  437,  455 

Bruit  d'airain  {see  Bell-sound),  143; 
de  drdpeau  in  plastic  bronchitis,  199; 
de  grelottement  ou  de  soupape  {see 
Foreign  bodies),  227,  234;  de  pot 
file,  39;  — in  tuberculous  excavation 
of  the  lung,  523 

Briining,  use  of  bronchoscopy  for 
removal  of  foreign  bodies  from  air- 
passages,  237;  X-ray  photograph 
showing  normal  distribution  and 
arrangement  of  the  bronchi,  Plate 
facing  p.  2 

Buchanan,  Sir  George,  dampness  of 
the  soil  and  phthisis,  450 

Bucks  and  Berks  Sanatorium,  results 
of  artificial  pneumothorax  at,  727 

Buhl  on  specific  nature  of  tubercle,  421 

Bull,  Professor,  cases  of  thoracoplasty 
in  phthisis,  728 

Bullar,  J.  F.,  experiments  on  produc- 
tion of  the  vesicular  murmur,  50 

Bulloch,  Professor  W.,  on  acid-fast 
properties  of  the  Bacillus  tuber- 
culosis, 423;  on  the  opsonic  index, 

584 

Bulstrode,  H.  T.,  age  of  maximum 
mortality  in  phthisis,  453;  report 
on  sanatorium  treatment,  619 

Buluwayo,  Rhodesia,  climate  of,  650 

Burrell,  L.  S.  T.,  apparatus  for  arti- 
ficial pneumothorax,  720 

Butter  bacillus,  424;  conveyance  of 
tuberculosis  by  means  of,  431 

Cacodylate  of  soda  (sodium  dimethyl- 
arseniate)  injections  in  febrile  cases 
of  phthisis,  677,  678 

Caffeine  for  asthma,  263 ;  in  pneumonia, 

315 

Cairo  to  be  avoided  for  phthisical 
patients,  665 

Calcium  chloride  and  calcium  lactate 
in  haemoptysis,  704 

Calcutta  in  winter  for  phthisis,  657 

California,  climate  of,  667 

Callipers  for  comparative  chest 
measurements,  24,  34 

Calmette,  Professor,  alimentary  in- 
fection in  tuberculosis,  431;  cobra 
venom  best  for  tuberculosis,  588 ;  con- 
junctival tuberculin  test,  579,  583; 
on  the  production  of  anthracosis,  339 

Calomel  in  asthma,  258;  in  pneumonia, 
311. 


INDEX 


1^1 


Cambridgeshire  Tuberculosis  Colony, 
Papworth  Hall,  622 

Campbell,  Colin,  treatment  of  bronchi- 
ectasis by  intralaryngeal  injections, 
219 

Canada,  immigration  laws  as  to  ad- 
mission of  tuberculous  patients  into, 
636,  656 

Canary  Islands:  climate  of,  667,  669; 
for  asthma,  256;  for  chronic  bron- 
chitis and  emphysema,  283;  for 
phthisis,  667,  669 

Cancer  and  haemoptysis,  546 

Cannes,  Riviera,  winter  climate  of, 
643,  659,  661;  for  anaemia,  asthma, 
senile  bronchitis,  emphysema, 
phthisis,  193,  662 

Canti,  R.  G.,  tuberculosis  of  bronchial 
glands  secondary  to  lung  focus,  471 

Cape  of  Good  Hope,  Province  of,  South 
Africa,  for  phthisis,  climate  of,  644 

Cape  Town  unsuitable  for  chest 
invalids,  644 

Cap  Martin,  Riviera,  for  wealthy 
patients,  663 

Carcinoma  of  lung,  primary  and 
secondary,  750,  751 ;  of  mediastinum, 

737,  738 

"  Carcinomatosis  "  of  lung,  751 

Carling,  Dr.  Esther,  results  of  artificial 
pneumothorax  at  Bucks  and  Berks 
Sanatorium,  727 

Carson,  James,  on  residual  tension  of 
the  lungs,  7 

Castellani,  A.,  on  organisms  found  in 
bronchitis  in  tropical  climates,  180 

Casts,  bronchial,  69;  in  asthma,  265; 
in  diphtheria,  69;  in  plastic  bron- 
chitis, 196  ;  in  pneumonia,  69 

Cat,  tuberculosis  in  the,  425 

Catarrh,  "autumnal"  in  America,  249; 
bronchial  (see  Bronchitis),  176;  dry, 
195;  of  nasal  or  intestinal  tract  and 
dentition,  176;  pituitous,  194 

Catarrhal  or  bronchitic  asthma,  248 

Catarrhe  sec,  195,  196 

Cauteret  for  asthma,  257 

Caux  for  phthisis,  637 

Cavernous  breathing,  55  (see  Breath- 
sounds);  rale,  42,  58  (see  Rales) 

Cavities  in  phthisis:  causing  total  ex- 
cavation of  lung,  and  suggesting 
pneumothorax,  149;  cicatrisation  of, 
529;  physical  signs  of,  523;  the 
quiescent,  528-530;  recent,  522-528; 
secreting,  530;  ulcerous  cavity,  530; 
treatment  of,  588-6gi;  — ,  surgical, 
729 

Cayley,  W.,  case  of  gangrene  of  the 
lung  treated  by  drainage,  recovery, 
362;  case  of  haemoptysis  treated  by 


the  induction  of  pneumothorax  so 
as  to  collapse  the  lung,  549,  719 
Cells  in  sputum,  70,  71 
Celsus'  description  of  phthisis,  420 
Cerebral  abscess  and  empyema,   125; 
(or   cerebellar)   abscess   in  bronchi- 
ectasis, 213 
Ceres,  South  Africa,  climate  of,  645 
Channels    of    infection   in   pulmonary 
tuberculosis,     427-433;     congenital, 
427;  ingestion  and  inhalation,  428- 
431 ;  inoculation,  427;  milk  infection, 

431-433 

Chaplin,  Arnold,  creosote  vapour  bath 
in  bronchiectasis,  217 

Chapman,  J.  E.,  Bardswell,  N.,  and 
Goodbody,  F.  W.,  metabolism  in 
phthisis,  613 

Chapman  and  Bardswell,  N.,  diet  for 
phthisical  patients,  614 

Charcot-Leyden  crystals,  75;  in 
asthma,  252;  in  bronchiectasis,  212 

Charles,  Dr.  (Cannes),  formula  for 
koumiss,  603 

Chateau  d'CEx  for  phthisis,  637 

Chausse,  Dr.,  inhalation  infection  in 
phthisis,  429,  430 

Chest,  alar,  79;  cup-like  hollow  de- 
formity of,  79;  deformity  from 
deficiency  of  clavicular  portion  of 
the  pectoral  muscle,  79;  diagram 
model  of,  12;  effect  on  heart  and 
circulation  of  conditions  in,  15; 
expansion  of,  on  puncturing  pleura 
after  death,  11;  inspection  of,  and 
what  it  leads  to,  33,  34;  measure- 
ments of,  23;  movements  of,  33; 
palpation  of,  33  (see  Palpation); 
percussion  of,  33,  35;  — ,  method,  35 
(see  Percussion);  physical  conditions, 
of,  12;  pigeon-breasted,  78;  physical 
signs  and  position  of  organs  in 
healthy,  38;  position  of  patient 
during  examination  of,  37;  reserve 
capacity  of,  17;  rickety,  78;  shape 
of,  23,  78;  stomach  note  in  healthy, 
38;  topography  of,  28,  29.  See  also 
under  "  Thoracic  " 

Chest  walls,  diseases  of,  79;  — , 
aponeurotic  rheumatism,  80;  — , 
intercostal  neuralgia,  80;  — ,  myal- 
gia, 80;  — ,  periostitis  and  peri- 
chondritis of  sternum  and  ribs,  82- 

84,734 
"  Chester  "  powder  for  asthma,  259 
Chexbres,  Switzerland,  autumn  health 

resort,  654 
Child,  state  of  lungs  in  new-born,  6 
Children,  bovine  tuberculosis  in,  432, 

433;    broncho-pneumonia    in,    327; 

pneumococcic  pleurisy  in,  118;  post- 


768 


DISEASES   OF   THE    LUNGS   AND    PLEURA 


diphtheritic  paralysis  and  massive 
collapse  of  the  lung  in,  345 ;  suitable 
schools  and  places  for  delicate,  594 

Chilterns,  the,  suitable  for  permanent 
residence  for  phthisical  patients  who 
have  regained  health,  669 

Chloral  in  asthma,  261;  in  bronchial 
narrowing,  205;  in  bronchitis,  189; 
in  mediastinal  tumours,  750 

Chloralamide  in  pneumonia,  316 

Chloride  of  ammonium  in  chronic 
bronchitis,  192 

Chlorine  poison  gas  and  acute  pul- 
monary oedema,  357 

Chloroform,  inhalation  of,  in  asthma, 
244,  260;  in  narrowing  of  bronchi, 
205;  in  surgical  operations  in  cases 
of  chest  disease,  128;  in  relief  of 
severe  symptoms  in  tuberculous 
laryngitis,  701 ;  in  tuberculous  menin- 
gitis, 710;  to  relieve  cough  in 
phthisis,  681 

Cholesterin  crystals  in  sputum,  75  ;  in 
chronic  pleural  effusion,  114 

Chorley  Wood  suitable  for  permanent 
residence  for  phthisical  patients  who 
have  regained  health,  669 

Chronic  and  fibroid  stage  of  pulmonary 
tuberculosis,  502-520  [see  Tuber- 
culosis); —  bronchitis,  igo  {see 
Bronchitis) 

Chylothorax,  166;  aetiology,  169;  age 
and  sex  incidence  in,  169;  causes 
producing,  169;  prognosis,  170; 
treatment,  171;  varieties:  the  true 
and  pseudo-chylous  forms,  166; 
means  of  distinguishing  between, 
167;  illustrative  case  of  the  pseudo- 
chylous variety,  171 

Cimiez,  Riviera,  suitable  for  asthmatic 
patients,  256,  662 

Cirrhosis  of  the  lung,  335 ;  see  Pneu- 
monia, interstitial 

Clacton-on-Sea  suitable  for  phthisical 
patients  in  autumn,  653 

Clark,  Sir  Andrew,  definition  of  fibroid 
phthisis,  511;  insistence  on  im- 
portance of  examination  of  sputum 
for  elastic  fibres,  73 ;  on  aetiology  of 
asthma,  247 

Clicking  sounds,  42,  45 

Cliftonville,     Margate,     suitable     for 

phthisis  in  autumn,  653,  654 
Climatic  change  in  the  treatment  of 
piilmonary  tuberculosis,  636-670 ; 
Algiers,  664;  Alpine  stations,  637; 
Andes,  the  South  American,  642; 
Argentine,  La  Cmnbre  district  of, 
650;  California,  667;  Canary  Islands, 
667;  Egypt,  664;  European  stations 
of    medium    elevation,   651;    Great 


Britain  {see  Great  Britain,  health 
resorts);  immigration  laws  restrict- 
ing travel,  636,  656;  India,  hill- 
stations  of,  650;  Madeira,  665; 
Riviera,  the,  659-663;  Rocky  Moun- 
tains, 641;  South  Africa,  642;  — , 
Province  of  Cape  of  Good  Hope, 
644;  — ,  of  Natal,  645;  — ,  of  Orange 
Free  State,  647;  — ,  of  Transvaal, 
649;  voyages,  sea,  in,  654-658;  see 
also  Health  Resorts  \ 

Clothing  of  consumptive  patient,  599 
Clubbing  of  fingers  in  bronchiectasis, 

214 
Coal-dust  causing  anthracosis,  338 
Cobbett,  Louis,  calculations  as  to  the 
amount      of      bovine     tuberculosis 
occurring    in    children    and    adults, 
432,    433;    congenital    infection    in 
tuberculosis,  427;  criticism  of  Pro- 
fessor   Calmette's    experiments    de- 
signed   to    show    that    pulmonary 
tuberculosis  is  the  result  of  alimen- 
tary infection,  431 
Cobra-venom  test  in  phthisis,  588 
Cod-liver  oil  and  its  administration  in 
phthisis,  674;  —  with  creosote,  675, 
687;  — with  other  vehicles,  675;  its 
effect   upon  metabolism   and  upon 
the  tubercle  bacillus,  674;  in  asper- 
gillosis, 417;  in  broncho-pneumonia, 
331;  in  chronic  bronchitis,  193 
Cod-liver     oil     emulsion,     Brompton 

Hospital  formula,  675 
Coffee  in  treatment  of  asthma,  260, 

263 
Coghill's  respirator,  218,  681 
Cog- wheeled  respiration,  52 
Cold  pack  or  cool  bath  in  pneumonia, 

312 
Colds,   neglected,    and   phthisis,    596; 

treatment  of,  596 
Colitis    as    a    complication    of    pneu- 
monia, 307,  309 
Collapse  of  lung,  344,  345 ;  massive  or 
lobar  in  character,  345 ;  — ,  aetiology, 
347;   — ,   clinical  features   of,    346, 
347;   — ,    contralateral   and   homo- 
lateral, 346;  — ,  diagnosis,  350;  — , 
mechanism  of  production,  348;  — , 
operations    and,    346;   — ,   physical 
signs,  346;  — ,  prognosis,  350;  — , 
treatment,  350;  — ,  varieties:  Group 
I.,  345;  Group  II.,  346 
Collective     Investigation     Committee, 
British  Medical  Association,  evidence 
as  to  personal  contagion  in  pneu- 
monia, 288 
Collingwood,  B.  J.,  and  Willcox,  W. 
H.,     therapeutic     use     of     alcohol 
vapour  mixed  with  oxygen,  315 


INDEX 


769 


Colonies,  immigration  laws  restricting 
admission  of  tuberculous  patients 
into,  636, 656 

Colony  treatment  of  phthisis,  622 

Colorado  Springs,  Rocky  Mountains, 
for  summer  and  winter  treatment  of 
phthisis,  641,  642 

Colwyn  Bay  suitable  for  bronchitis,  193 

Complement-fixation  test  in  hydatid 
disease  of  the  lungs,  370;  in  pul- 
monary tuberculosis,  587 ;  in  syphilis, 
388,  392 

Compressed-air  bath;  see  Bath,  com- 
pressed-air 

Conjugal  or  marital  tuberculosis,  437 

"  Consumption  "  an  appropriate  term, 
420 

Consumption  hospitals  and  question 
of  personal  infection,  435 

Convulsions  in  children  in  pneumonia, 
296;  in  tuberculous  meningitis,  565 

Copaiba  in  bronchiectasis,  218 

Cornet,  Professor,  tubercle  bacilli  in 
sputum,  429 

Cornish  miners  and  excessive  mor- 
tality from  phthisis,  456 

Corvisart,  employment  of  percussion, 

35 

Costal  abscess,  83;  angle,  33 

Costebelle,  Riviera,  suitable  for 
phthisis,  661 

Cotton,  aneurism  of  pulmonary  artery, 
548 

Cough :  after  inhalation  of  foreign 
bodies,  233,  234;  and  hsematemesis, 
551;  and  mediastinal  tumours,  739, 
740;  clanging,  brassy,  or  husky 
character  in  empyema,  123;  in 
bronchial  narrowing,  204;  in  hy- 
datid disease  of  the  lungs  before 
rupture,  368;  in  laryngeal  tuber- 
culosis, repression  of,  698;  in 
phthisis,  irritable  and  ineffectual, 
682;  — ,  morning,  special  treatment 
of,  682;  — ,  night,  special  treatment 
of,  682;  — ,  relief  of,  in  acute  first 
stage,  672;  — ,  repression  of,  in 
quiescent  cavity  period,  689;  — , 
treatment  of,  local  and  general,  680 ; 
— ,  with  vomiting,  516;  treatment 
of,  708 
"g» Counter-irritation  in  laryngeal  tuber- 
culosis, 699;  in  pneumonia,  313,  317; 
in  pleurisy,  8g,  108,  708;  in  secret- 
ing and  ulcerous  cavities,  690,  691 

Coupland,  Sidney,  sketch  of  elastic 
tissue  and  fragment  of  small  vessel 
from  expectoration  of  patient  with 
rapidly  forming  cavities,  476;  evi- 
dence of  personal  contagion  in 
pneumonia,  289 


Courmont,  Professor,  agglutination 
test,  589 

Cows,  tuberculosis  in,  425;  see  Bovine 
tuberculosis  and  Perlsucht 

"  Crachats  perles,"  196 

"Cracked-pot  sound"  (bruit  de  pot 
fele),  39 

Crackling  rales,  42 

"Cradling"  to  reduce  pyrexia,  311, 
312 

Cragmor  Sanatorium,  Colorado  Springs, 
641 

Craighead,  J.  W.,  and  Marshall,  M.  I., 
on  perforation  or  rupture  of  lung 
complicating  artificial  pneumo- 
thorax, 724 

Cremator  at  Brompton  Hospital  for 
disposal  of  sputum,  600 

Creosote  group  of  drugs,  use  of,  in 
bronchiectasis,  218,  219 

Creosote  in  chronic  bronchitis,  193; 
in  gangrene  of  the  lungs,  365;  in 
laryngeal  tuberculosis,  698;  in  pul- 
monary tuberculosis,  687,  688,  732; 
vapour  bath  in  bronchiectasis,  217, 
218 

Crepitation  (crepitant  rale),  definition 
and  significance,  42;  international 
nomenclature,  45;  fine  hair,  42,  59, 
296,  297;  redux,  in  pneumonia,  300 

Crossley  Sanatorium,  statistics  dealing 
with  the  hereditary  factor  in  pul- 
monary tuberculosis  at,  445,  446 

Croydon  suitable  for  permanent  resi- 
dence for  quiescent  cases  of  phthisis, 
669 

Cryogenin  in  pyrexial  cases  of  phthisis, 
679 

Crystals  in  sputum,  75 

Cuneo,  B.;  and  Poirier,  P.;  see  Poirier, 
P.,  and  Cuneo,  B. 

Cupping,  dry,  in  bronchitis,  189 

Curie,  David,  intensive  iodine  treat- 
ment of  phthisis,  678 

Curschmann,  "  bronchiolitis  exuda- 
tiva," 242;  spirals  in  asthma,  252; 
—  in  sputum,  74 

Cutlers  and  phthisis,  455 

Cyrtometer,  the,  24,  34,  102 

Dally,  Halls,  mechanism  of  respira- 
tion, 345 

Damoiseau's  curve,  98 

Dampness  of  soil,  influence  of,  on 
phthisis  mortality,  450 

Daneswood  Sanatorium,  exercise  and 
work  at,  611 

Darjeeling,  India,  climate  of,  650;  for 
phthisis,  657 

Darling  Downs,  Queensland,  for 
phthisis,  657 

49 


770 


DISEASES   OF   THE    LUNGS   AND   PLEURA 


Dartmoor  for  asthma,  256 

Datura  tatula  cigarettes  for  asthma, 
260 

Davidson,  Sir  Mackenzie,  stereoscopic 
method  of  X-ray  examination,  64 

Davies,  H.  Morriston,  case  of  rib- 
mobilisation  in  bronchiectasis,  221; 
on  oxygen  replacement  following 
aspiration  in  chronic  sero-fibrinous 
effusion,  114 

Davos,  Switzerland,  cases  of  phthisis 
suitable  for  treatment  at,  639; 
features  and  special  climatic  pro- 
perties of,  637-639,  642,  643;  for 
asthma,  256 

Davy,  John,  gas  analyses  in  pyo- 
pneumothorax, 139 

Dax  for  catarrhal  asthma,  256 

Debove's  method  of  feeding  phthisical 
patients,  601 

Decortication  of  lung,  operation  for, 
in  old-standing  empyemata,  129 

Delbret,  Professor,  surgical  treatment 
of  pulmonary  emphysema,  283 

Delirium  tremens  in  pneumonia,  310 

Delorme's  operation  for  decortication 
of  the  lung,  129 

Denison,  C,  law  of  increasing  dia- 
thermancy of  air  with  rising  alti- 
tude, 638 

Dentition,  bronchitis  in  infants  at  time 
of  first,  176 

Denver,  Colorado,  for  phthisical 
patients,  641 ;  winter  climate  of, 
642,  643 

Denys'  tuberculin,  714 

Dermoid  tumours,  intrathoracic,  379; 
age  and  sex  incidence,  380;  fatal 
termination  if  untreated,  381;  illus- 
trative case,  382;  relation  to  tera- 
tomata,  380,  383,  384;  sites  of,  379; 
symptoms,  including  expectoration 
of  hairs,  380;  treatment,  381;  — , 
surgical,  381 

Derry,  D.  E.,  and  Smith,  EUiott, 
evidence  of  tuberculosis  in  early 
Egyptian  skeletons,  419 

Dettweiler,  introduction  of  sanatorium 
treatment  for  phthisis,  607 

Devonshire  moorland  districts  suit- 
able for  phthisical  patients  in 
autumn,  653 

Dewar,  Sir  James,  destructive  power 
of  ultra-violet  rays  upon  bacteria, 

639 
Diabetes:  and  abscess  of  the  lung,  359; 
and  caseo-pneumonic  tuberculosis, 
486;  and  relation  to  pulmonary 
tuberculosis  (discussion  at  the 
Pathological  Society),  486;  and 
sloughing  pneumonia,  487 


Diamethyl-amido-benzaldehyde  reac- 
tion in  phthisis,  570 

Diaphragm:  depression  of,  in  pyo- 
pneumothorax, 143,  144;  effect  of 
pleural  effusion  upon,  99,  103; 
hernia  of,  leading  to  symptoms 
suggestive  of  pneumothorax,  149; 
lymphatics  of,  communication  be- 
tween pleural  and  peritoneal  sur- 
faces of,  19;  movements  of,  in 
phthisis,  575;  not  elastic  per  se,  14; 
yielding  capacity  to  traction  of 
lungs,  14;  pleurisy  of,  88 

Diaphragmatic  pleurisy,  88 

Diarrhoea  in  intestinal  tuberculosis, 
542 ;  in  lardaceous  degeneration  com- 
plicating phthisis,  569;  in  suppura- 
tive pleurisy,  120;  tuberculous, 
treatment  of,  694-697 

Diathermancy  of  air  in  high  altitudes, 
638 

Diathesis,  the  tubercular,  445-448 

Dichlor-ethyl-sulphide  (mustard  gas), 
producing  broncho-pneumonia,  324 

Dickinson,  W.  H.,  on  the  organs 
chiefly  affected  in  lardaceous  disease, 
568 

Diet;  in  asthma,  257;  in  pneumonia, 
313;  — ,  restraint  in,  313;  in  pul- 
monary hsDmoptysis,  703;  in  pul- 
monary tuberculosis,  601,  604;  — , 
calorie  value  of,  614;  — ,  early 
stages,  613-616;  — ,  period  of 
softening  and  formation  of  cavities, 
685;  — ,  standard  diet  at  the  King 
Edward  VII.  Sanatorium,  615;  — , 
in  tuberculous  ulceration  of  the 
bowel,  694-696 

Dieulafo}',  paracentesis  thoracis,  109 

Digitalis  in  asthma,  263;  in  bronchitis, 
189;  in  emphysema,  280;  in  oedema 
of  the  lungs,  354;  in  pneumonia, 
314,  315,  316 

Diphtheria,  bronchial  casts  in,  69; 
followed     by     broncho-pneumonia, 

323.  325 
Diplococcus     lanceolatus     and     Diplo- 

coccus    pneumonice ;    see    Pneumo- 

coccus 
Discomyces,     genus      to     which     the 

streptothrix  belongs,  394 
Dittrich's  plugs  in  sputum  of  bronchi- 
ectasis, 212 
Diuretics     in     recurrent     pulmonary 

oedema,  356 
Dixon,  W.  E.,  and  Brodie,  T.  G.;  see 

Bodrie,  T.  G.,  and  Dixon,  W.  E. 
Dodwell,  P.  R.,  and  Fen  wick,  W.  S., 

perforation    of    the    intestine    from 

tuberculous  ulceration  of  the  bowel 

in  phthisis,  541 


INDEX 


771 


Dog,  muscular  tissue  in  lung  of,  8; 
tuberculosis  in,  425 

Donders,  residual  tension  of  the  lungs, 
7,8 

Douglas,  C.  G.,  and  Haldane,  J.  S., 
on  mechanism  of  absorption  of 
oxygen  by  the  lungs,  5 

Dreschfeld,  Professor,  migratory,  creep- 
ing, or  wandering  pneumonia,  304 

Drowsiness  in  tuberculous  meningitis, 

_  566 

Dry  crackle  of  Laennec,  59 

Dry-cupping  in  pulmonary  oedema, 
354,  356;  in  pneumothorax,  151 

Dunbar,  Professor,  setiology  of  hay 
asthma,  248;  poUantin,  specific 
serum  for  hay  asthma,  262;  treat- 
ment of  hay  asthma,  262 

Durban,  Natal,  climate  of,  647 

Durham,  Arthur,  mortality  from 
foreign  bodies  in  air-passages,  238 

Dust:  as  exciting  cause  of  asthma, 
247;  illustrative  case  from  rose- 
wood dust,  264;  as  exciting  cause 
of  bronchitis,  178;  and  of  pneumo- 
koniosis,  338;  ■ — ,  infected,  an  im- 
portant factor  in  the  spread  of 
tuberculosis,  429,  430;  occupations 
rendered  harmful  by,  178,  338,  340 

Dyspepsia  from  swallowing  expectora- 
tion, 602 

Dysphagia  in  mediastinal  tumours, 
740;  in  tuberculous  laryngitis,  699 

Dyspnoea:  hysterical,  150;  in  medi- 
astinal tumours,  740,  750;  in  pneu- 
monia, 296;  in  pneumothorax,  some- 
times suggesting  asthma,  150 

Ear,  tuberculous  disease  of  the  middle, 
539 

Eastbourne  for  autumn  treatment  of 
phthisis,  654 

Eau  de  goudron  (Guyot)  for  secret- 
ing cavities,  690;  in  chronic  bron- 
chitis, 192 

Eaux  Bonnes  for  asthma,  257;  summer 
health  resort,  669 

Eczema  and  asthma,  245 

Edwards,  Vertue,  health  of  staff  at 
Brompton  Hospital,  436 

Effusion,  pleural:  acute  sero-fibrinous, 
90;  commonly  tuberculous  in  nature, 
90-92;  chronic  sero-fibrinous,  114; 
complicating  mediastinal  growths, 
743;  physical  signs  of,  97-105;  see 
also  Pleurisy 

Egypt:  as  health  resort,  climate  of, 
664-665;  suitable  for  bronchitic 
asthma,  665;  —  for  bronchitis  and 
emphysema,  193,  283;  — for  certain 
cases  of  chronic  phthisis,  665 


Ehrlich'  s  diamethyl-amido-benzalde- 
hyde  reaction,  570 

Eichhorst  on  tuberculous  pleurisy,  91 

Eicken,  Professor  von,  removal  of 
foreign  bodies  by  superior  or  in- 
ferior bronchoscopy,  238 

Elastic  fibres  in  abscess  of  the  lung, 
306,  360;  in  gangrene  of  the  lung, 
364;  in  phthisis,  476,  488,  526;  in 
sputum,  72,  73 

Elderton,  Ethel  M.,  Pearson,  Karl,  and 
Pope,  E.  G.,  on  frequency  of  con- 
jugal tuberculosis,  438 

Elderton,  W.  P.,  and  Perry,  S.  J., 
conclusions  as  to  the  value  of  tuber- 
culin treatment  at  the  Adirondack 
Sanitarium,  717;  results  of  sana- 
torium treatment,  625,  626 

Elliott,  T.  R.,  bronchial  contraction 
and  massive  collapse  of  lung,  349; 
— ,  and  Henry,  H.,  on  haemothorax, 
157,  160 

Ellis's  letter  S  curve  in  pleural  effusion, 
98 

Emetics  in  whooping-cough  to  avert 
broncho-pneumonia,  329,  330 

Emphysema,  general,  pulmonary  vesi- 
cular :  large-lunged  emphysema,  269 ; 
aBtiology,  273-275;  associated  with 
asthma,  242,  248,  253,  254;  — , 
chronic  bronchitis,  191 ;  — ,  pneumo- 
koniosis,  340;  — ,  phthisis,  not 
suitable  for  elevated  climates,  640; 
atrophic  changes  of  lung  in,  270, 
271,  275;  compensatory  changes  in, 
272;  failure  of  right  heart  in,  271, 
272;  loss  of  lung  elasticity  in,  274; 
pathology  and  morbid  anatomy  of, 
269;  sex-incidence  in,  269;  symp- 
tomatology, with  illustrative  case, 
277,  279;  texture  of  lungs  impaired 
in,  270;  treatment  of,  279-283;  — , 
climatic,  282;  — ,  compressed-air 
baths  in,  281;  — ,  medicinal,  279; 
— ,  surgical,  283;  varieties  of:  small- 
lunged  or  senile  emphysema,  276; 
wind  instruments  and,  273 

Emphysema:  interstitial  or  inter- 
lobular, 284;  — ,  associated  with 
whooping-cough  and  phthisis,  284 

Emphysema,  local  pulmonary  vesi- 
cular, 275 

Emphysema,  surgical,  135,  284 

Empyema,  or  suppurative  pleurisy, 
118;  aetiology,  118;  bacteriology, 
119;  blood-count  in,  121;  course,  if 
untreated,  125;  determination  of 
the  purulent  nature  of  the  effusion 
in,  121;  diagnosis,  125;  physical 
signs  of,  120;  pulsation  of  fluid  in 
rare  cases  simulating  aneurism,  121; 


772 


DISEASES   OF  THE    LUNGS   AND   PLEURiE 


rupture     through     bronchus,     125; 
leading  sometimes  to  pneumothorax, 
135;    S3'mptoms    of,    119;    treatment 
of,  by  resection  and  drainage,  127; 
— ,  during  convalescence,   129;  — , 
nature    of    anaesthetic    to    be    used 
during  operation,   128;  — ,  of  old- 
standing  cases  by  lung  decortication 
or  thoracoplasty,  129,  130;  — ,  when 
associated  with  influenza,  130;  varie- 
ties of :  double,  130;  — ,  foetid,  r23 
— ,  localised  or  encysted,   124;  — 
mediastinal  and  diaphragmatic,  124 
r25;    — ,    migratory    or    wandering 
125;   — ,    pulsating,    121,    122;   - 
tuberculous,  123,  r3r;  in  association 
with    dermoid    cyst    of    the    chest 
382;   — ,  foreign  body  in  bronchus 
235;    — ,    influenza,    130,    131;    — 
phthisis,  r3i;  — ,  pneumonia,   307 
— ,  streptotrichosis,  408 
Ems  for  gouty  bronchitis,  194;  summer 
health  resort,  669;  water  spray  in 
laryngeal  tuberculosis,  699  j 

Enchondroma  of  mediastinum,  737  I 

Endocarditis,     malignant,     in     pneu-    1 

monia,  306-308 
Enema,  nutrient,  in  laryngeal  tuber- 
culosis, 701 ;  starch  and  opium,  for    ; 
diarrhoea,  697 
England,  hay  asthma  in,  248;  health 

resorts  in  [see  under  Great  Britain) 
Eosinophilia     in     asthma,      252;     in 
hj'datid  disease  of  the  lungs,  369, 370 
Epistaxis  and  false  haemoptysis,  557; 

in  influenzal  pneunionia,  332 
Ergot  in  haemoptysis,  705 ;  706 
Estcourt,  South  Africa,  climate  of,  647 
Estes  Park,  Colorado,  summer  resort 

for  phthisis,  642 
Estlander's  operation:  in  pyo-pneumo- 
thorax,  152;  in  suppurative  pleurisy, 
130;  in  bronchiectasis,  220 
Ether   in   confection  of  turpentine  in 
pneumonia,     315;     inhalation     of, 
leads    to    relaxation    of    bronchial 
spasm  and  removal  of  sibilant  sounds    ! 
in  asthma,  56;  paralysis  of  nerve- 
endings  in  bronchi  from  inhalation 
of,  244;  unsuitable  as  an  anassthetic 
in  chest  disease,  128,  324 
Ethyl,  iodide  of,  in  asthma,  260 
Eucalyptus  in  secreting  cavities,  690 
"  Eupnine  "  in  asthma,  260 
Ewald,     analysis    of    air-contents    in 

pneumothorax,  139 
Ewart,  W.,  researches  into  structure 

of  bronchial  tree,  2,  197 
Exercise    and    work    in    sanatorium 
treatment,    grades    of,    at    Frimley 
Sanatorium,  609,  610 


Expectoration:  albuminous  or  serous > 
in  acute  pulmonary  oedema,  353, 
354;  — ,  following  paracentesis  of 
chest,  ri4;  see  also  Sputum 

Exploring  syringe,  use  of,  in  suppurat- 
ing pleurisy,  121;  — ,  in  abscess  of 
the  lung, 36r 

Eyre,  J.  W.  H.,  bacteriology  of  acute 
broncho-pneumonia,  325 

Fagge,  Hilton,  on  percussion  note,  46 
Falkenstein,  Taurus  Range,  sanatorium 

for  phthisis  at,  65  r;  calorie  value  of 

diet  at,  613 
Falmouth  for  chronic  bronchitis  and 

emphysema,    193,    283;    for   winter 

treatment  of  phthisis,  654,  658 
Fanning,      Burton,      after-results     of 

treatment    at    KeUing    Sanatorium., 

621 
Farnborough  for  asthma,  256 
Faroe    Islands,    prevalence    of    tuber- 
culosis   in,    though   Perlsucht    only 

recently  introduced,  433 
Fats  in  treatment  of  phthisis,  676 
Fearn,    S.    W.,    describes    first    case 

of  aneurism  of   pulmonar}'    artery, 

548 
Fenwick,  Samuel,  method  of  detecting 

elastic  fibres  in  sputum,  72 
Fenwick,    W.    Saltan,    and    Dodwell, 

P.   R.,  perforation  of  the  intestine 

from     tuberculous     ulceration      of 

bowel  in  phthisis,  541 
Fibrinous  bronchitis,  197 
Fibroid    phthisis,    5ir;    see    Phthisis, 

fibroid 
Fibroma  of  mediastinum,  737;  of  lung, 

750 
Fibrosis  of   lung,  467;  see  also  Pneu- 
monia, interstitial 
Filter-passing  virus  in  influenza,  331, 

332 
Findel,  researches  on  respiratory  and 

alimentary  infection  in  tuberculosis, 

431 

Fine-hair  crepitation,  56;  in  pneu- 
monia, 297,  300 

Fingers,  clubbing  of,  in  bronchiectasis, 
2r4 

Fistula  in  ano  in  pulmonary  tuber- 
culosis, 570;  rarely  occurring  in 
females  in  this  disease,  571;  treat- 
ment of,  571 

Flack,  effect  of  oxj^gen  during  and 
after  aerial  flights  and  prolonged 
athletic  efforts,  315 

Fleuren's  nceud  vital,  or  ganglion  of 
life,  6 

Flint,  Austin,  on  cavernous  breath- 
sounds,  55;    on  duration  of  life  in 


INDEX 


773 


consumptive  patients  in  pre-sana- 
torium  days,  based  upon  the  records 
of  his  private  patients,  626 

Florence,  Italy,  unsuitable  for  phthisis, 
669 

Fliigge,  Professor,  theory  of  infection 
in  phthisis  by  "droplets"  of  in- 
fected sputum,  429 

Focal  reaction  to  tuberculin  test,  582 

Foetid  bronchitis,  192;  see  also  Bron- 
chitis 

Foetor  of  breath  and  sputum  in 
bronchiectasis,  212;  in  foetid  bron- 
chitis, 192;  in  gangrene  of  the  lung, 
364;  treatment  of,  192,  193 

Foetus,  state  of  lungs  in,  6;  rarity  of 
tuberculosis  in,  427 

Folkestone  suitable  for  phthisis  in 
autumn,  654;  for  school  for  delicate 
children,  594 

Food,  tuberculosis  conveyed  by,  430- 
433;  entering  air-passages  causing 
deglutition  pneumonia,  324;  see  also 
Diet 

Forbes,  J.  Graham,  method  of  detect- 
ing tubercle  bacillus  in  cerebro- 
spinal fluid, 56/ 

Foreign  bodies  in  air-passages,  223- 
241;  age-incidence  in  patients,  225; 
causing  abscess  of  lung,  359;  — 
bronchiectasis,  228;  cough  following 
inhalation,  229,  232,  233;  diag- 
nosis, 235 ;  — ,  by  bronchoscopy,  236; 
— ■,  by  X-rays,  235 ;  historical  ac- 
couirt,  223;  pathology,  227;  physical 
signs  of,  234;  — ,  "  bruit  de  grelotte- 
ment,"  234;  position  of,  227;  — , 
rarely  in  larynx,  227;  — ,  occasion- 
ally in  trachea,  227;  — ,  gener- 
ally in  bronchus,  227;  prognosis, 
236;  rough  and  angular  cause  more 
irritation  than  round  and  smooth, 
232;  scrutiny  of  history  of  attack 
suggesting  inhalation  important, 
233;  sex-incidence  in  patients,  225; 
statistics,  226;  symptoms,  case 
illustrating,  229,  232;  — ,  lull  in, 
following  initial  dyspnoea,  229, 
232,  233;  treatment  by  removal 
by  bronchoscopy  (superior  or  in- 
ferior), 237,  238;  — ,  by  inversion 
of  patient  with  tracheotomy,  239; 
— ,  by  tracheotomy  and  forceps,  if 
other  means  not  available,  239;  — , 
by  pneumotomy,  239;  — ,  general 
principles,  237 

Forlanini,  Professor,  artificial  pneumo- 
thorax, 719 

Formalin,  effect  of,  on  Bacillus  tuber- 
culosis, 425 
Forsyth,  C.  E.  P.,  and  Williams,  O.  T., 


experiments  with  cod-liver  oil  eluci- 
dating its  action  in  phthisis,  674 
Foulerton,  Alexander,  cases  of  primary 
streptothrix  disease  (actinomycosis), 
407;    researches  on  streptotrichosis, 

394 

Foundling  Hospital,  boys  trained  for 
regimental  band  in,  showing  absence 
of  emphysema,  273 

Fowl,  tuberculosis  in  common,  426 

Fowler,  Sir  J.  Kingston,  case  of 
pneumothorax  resulting  from  a 
ruptured  emphysematous  bulla,  135 ; 
on  frequency  of  occurrence  of 
lardaceous  disease  in  chronic  pul- 
monary tuberculosis,  567;  on  extent 
of  lung  affected  in  bronchiectasis, 
208;  on  localisation  of  lesions  in 
phthisis,  470;  on  pulmonary  syphUis, 
386 

Fox,  WUson,  atlas  of  pathologica 
anatomy  of  the  lungs,  497 ;  malignant 
tumours  of  the  mediastinum,  737 

Frankel,  study  of  pneumococcus,  289 

Frankland  on  rarefied  air,  283 

Freeman,     John,     and     Watson,     J 
Chandler,     anaphylactic    origin     of 
asthmatic  at  ack,  245 

Fremitus:  friction,  35,  39,  441  rhoncal, 
35,  39,  44,  57;  — ,  and  stridor,  57; 
vocal  (vocal  vibration),  35,  39,  44 

French,  Herbert,  Abrahams,  A.,  and 
Hallows,  Norman;  see  under  Abra- 
hams, A.,  Hallows,  Norman,  and 
French,  Herbert 

Freund,  W.  A.,  calcareous  degenera- 
tion of  cartilages  and  ribs  as  a  cause 
of  emphysema,  274;  operation  for 
pulmonary  emphysema,  283 

Friction,  pleural,  43,  45;  — ,  ^Y  and 
moist  varieties  of,  60;  — ,  Hippo- 
cratic  description  of,  60;  pleuro- 
pericardial,  5o,  96 

Friedlander's  bacillus  in  broncho- 
pneumonia, 325 ;  in  pneumonia,  290 

Friedrich,  observations  showing  the 
streptothrix  nature  of  the  Bacillus 
tuberculosis,  422 

Frimley  Sanatorium,  diet  at,  616; 
graduated  labour  at,  609,  610;  non- 
infection  from  telephone  mouthp  ece 
used  by  patients  at,  435 

Funchal,  Madeira,  climate  of,  665,  666; 
climatological  data  from,  643;  see 
also  Madeira 

Furniture  of  sick-room,  607 

Gaide,     displacement     of     heart     in 

pneumothorax,  146 
Gairdner,     Sir     William,     inspiratory 

theory  of  emphysema,  274 


774 


DISEASES    OF   THE    LUNGS   AND    PLEURA 


Galen,  description  of  phthisis  by, 
420;  plastic  bronchitis  observed  by, 
196 

Galvano-cautery  in  laryngeal  tuber- 
culosis, 699 

Gamaleia,  acute  lobar  pneumonia  ex- 
perimentally produced  in  sufficiently 
resistant  animals,  289 

Gangrene  of  the  lung,  362;  aetiology, 
363;  bacteriology  of,  364;  circum- 
scribed and  diffuse,  362,  363;  com- 
plicating acute  pneumonia,  306,  363; 
leading  to  pneumothorax,  148 ; 
physical  signs,  364;  symptoms,  364; 
treatment:  medicinal,  365;  surgical, 
with  recent  results  of,  365 

Garland,  G.  M.,  on  stomach  note  in 
pleural  effusion,  103 

Garlic  in  bronchiectasis,  218;  in 
whooping-cough,  330 

Garre,  C,  and  Quincke,  H.,  mortality 
after  surgical  treatment  of  gangrene 
of  the  lung,  365 ;  results  of  surgical 
treatment  of  abscess  of  the  lung,  360 ; 
results  of  surgical  treatment  of 
hydatid  disease  of  the  lung,  377 

Gas  embolism,  danger  of,  in  treatment 
by  artificial  pneumothorax,  723 

Gask,  Professor,  on  surgical  treatment 
of  hsemothorax,  162,  163 

Gee,  S.  J.,  case  of  pituitous  catarrh, 
195;  inspiratory  theory  of  emphy- 
sema, 274;  modification  of  cyrto- 
meter,  24;  on  meaning  of  term 
"  blenna,"  191;  on  physical  signs  of 
receding  pleural  effusion,  105 

Geissler  on  herpes  in  pneumonia,  310 

Ghon,  A.,  on  primary  lung  focus  in 
bronchial  gland  tuberculosis  in 
children,  471 

Gimbert  and  Bouchard,  C,  on  the  use 
of  creosote  and  guaiacol  in  phthisis, 
■687 

Glands,  bronchial,  tuberculosis  of,  471, 
472 

GlengarifE  suitable  for  bronchitis,  193 

Glion,  Switzerland,  for  phthisis,    641, 

651 

Glottis,  effect  on  voice  of  destruction 
of,  61 

Goat's  milk  in  phthisis,  603 

Godlee,  Sir  Rickman  J.,  details  of 
surgical  operation  in  abscess  of  lung, 
362;  emp3'ema,  site  of  incision  for, 
128;  on  pulmonary  streptotrichosis, 
408 

Gold  Coast,  tuberculosis  rife  in,  though 
milk  unobtainable,  433 

"  Gold-miner's  phthisis,"  with  illustra- 
tive case,  340-342,  455 

Golder's  Green  suitable  for  permanent 


residence  for  phthisical  patients  who 
have  regained  health,  669 

Goodbody,  F.  W.,  Bardswell,  N.,  and 
Chapman,  J.  E.,  613;  see  BardsweU 

Gorbersdorf,  Silesia,  sanatorium  for 
phthisis,  651 

Gordon,  Mervyn  H.,  on  types  of  the 
meningococcus  and  the  use  of 
"  monotypical  serum  "  in  treatment 
of  cerebro-spinal  fever,  3r8;  — ,  on 
the  dissemination  of  droplets  in 
speaking  and  declaiming,  429 

Gordon,  William,  influence  of  damp 
and  wind  on  phthisis,  449,  450 

Goring,  C,  on  marital  infection  and 
"  assortative  mating,"  439 

Gould,  Sir  A.  Pearce,  and  Cayley,  W., 
case  of  pulmonary  abscess  treated 
surgicall5%  recovery,  362 

Gout  and  bronchitis,  177;  liability  to 
pneumonia,  287 

Gouty  asthma,  245,  249;  subjects  and 
haemoptysis,  549 

Graaf  Reinet,  South  Africa,  climate 
of,  645 

Grabowsee  Sanatorium,  Germany,  diet 
at,  613 

Gram's  method  of  staining,  395,  396 

Grand  Canary  suitable  for  asthma, 
256;  —  for  chronic  bronchitis  and 
emphysema,  283;  see  also  Canary 
Islands 

Grange  for  bronchitis,  193 ;  for  phthisis, 
in  spring  and  autumn,  654,  668 

Grape  cure,  602,  606,  651 

Grasse,  spring  health  resort,  669 

Gray,  John,  results  of  sanatorium 
treatment  at  the  Stanhope  Sana- 
torium, Weirdale,  Durham,  620 

Great  Britain:  health  resorts  of,  193, 
256,  257,  653,  654,  658,  668,  669; 
— ,  for  asthma,  256,  257;  — ,  for 
bronchitis  and  emphysema,  193,  283 ; 
— ,  for  phthisis  in  autumn,  653,  654; 
spring,  668;  summer,  669;  in 
winter,  658;  suitable  localities  for 
permanent  residence  near  London 
for  phthisical  patients  who  have 
regained  health,  669 

Great  Missenden  suitable  for  perma- 
nent residence  for  phthisical  patients 
who  have  regained  their  health,  669 

Green,  Alan,  experimental  production 
of  lardaceous  disease,  569 

Greenhow,  E.  H.,  dust  inhalation  and 
phthisis,  455;  failure  of  nutrition  in 
emphysema,  274 

Greenland,  tuberculosis  rife  in,  though 

milk  unobtainable,  433 
"  Green      Mountain "      powder      for 
asthma,  259 


INDEX 


"775 


Greytown,  South  Africa,  climate  of, 
647 

Griffith,  Stanley,  cultivation  of  tubercle 
bacillus,  424 

Grindelia  robusta  in  asthma,  259,  262 

"  Grindeline  "  in  asthma,  262 

Grinders  and  phthisis,  455,  456 

Grisons  Canton,  table  showing  preva- 
lence of  tuberculosis  at  varying 
altitudes  in,  449 

Grocco's  paravertebral  triangle  of 
dulness,  104 

Grysez  and  Vansteenberghe,  P.,  ex- 
periments on  channels  of  infection 
in  pulmonary  tuberculosis,  431 

Guaiacol  in  laryngeal  tuberculosis,  698 ; 
in  quiescent  phthisis,  687,  688 

Guimbellot,  M.,  results  of  thoracotomy 
in  hydatid  disease  of  the  lung,  377 

Guinea-pig,  tuberculosis  in,  425 

Gull,  Sir  W.,  on  destructive  changes  in 
the  lung  following  pressure  on  bron- 
chus, 203 

Gulland,  G.  L.,  and  Goodall,  A.,  leuco- 
cyte count  in  acute  pulmonary  tuber- 
culosis, 476 

Gunshot  wounds  of  the  chest,  157-165 
(see  under  Haemothorax);  leading  to 
massive  collapse  of  lung,  346;  - — 
suppurative  mediastinitis,  734 

Haematemesis,  diagnosis  of  hsemop- 
tysis  from,  551 

Haemophilia,  haemorrhage  in,  causing 
true  and  spurious  haemoptysis,  547, 
562 

Haemopneumothorax,  158;  simulated 
by  septic  haemothorax  containing 
gas-forming  organisms,  161 

Hcemoptysis:  false  or  spurious,  546, 
557-562;  — ,  anatomical  line  of  divi- 
sion from  true  haemoptysis,  557;  — , 
conditions  under  which  it  occurs, 
557;  — ,  diagnosis  from  true,  561;  — , 
dietetic  errors  a  cause  of,  559;  — , 
— , feigned  or  hysterical  558;  ■ — , 
treatment,  559-562 

Haemoptysis:  true,  546;  appearance  of 
the  blood  expectorated,  550;  causes 
of,  546;  definition  of,  546;  diagnosis 
from  haematemesis  and  spurious 
haemoptysis,  551 

arising  from  active  hyperaemia, 
547;  from  aneurism  of  pulmonary 
artery,  547,  549;  from  erosion  of 
vessels,  547 

cases  ending  fatally,  548,  549; 
— ,  first  symptom  of  pulmonary 
tuberculosis  ("Phthisis  ab  haemop- 
toe"),  547 

in  acute  pneumonic  phthisis,  476; 


— ,  in  fibroid  phthisis,  519;  — ,  in 
phthisis  complicated  by  syphilis, 
392;  — ,  in  quiescent  phthisis  leading 
to  "  recurrent  haemoptysis,"  with 
illustrative  case,  552,  555;  special 
treatment  of,  707 

occurring  in  abscess  of  lung,  555; 
in  asthma,   253;    in  bronchiectasis, 
213;  in  bronchitis,  549;  in  foreign 
bodies  in  air-passages,  234;  in  gan- 
grene of  the  lung,  364  ;  in  hydatid 
disease,    374;    in    influenzal    pneu- 
monia,   332;    in    intrathoracic   der- 
moid, 380;  in  malignant  disease  of 
the  lung,  752;  in  malignant  disease 
of  the  mediastinum,  739;   in  pneu- 
monia, 310;  in  pulmonary  syphilis, 
388,   549;  in  wounds  of  the  chest, 
159;     in    pulmonary    tuberculosis, 
547,  556;  prognosis,  552;  — ,  treat- 
ment of,   702-708;  absolute  rest  in, 
702,  706;  by  artificial  pneumothorax, 
707-719;     diet    in,   703-706;    drugs 
in,  703-706;  summary  of,  706;  type 
of  case  unsuitable  for  treatment  at 
high  altitudes,  640 
Haemothorax,     157-165;     amount     of 
blood  effused  in,  157;  definition  of, 

157 

Hemothorax  following  wounds  of  the 
chest,  159;  — ,  bacteriology,  160; 
■ — •,  course:  if  sterile,  160;  if  septic, 
160;  ■ — ,  physical  signs  sometimes 
attended  by  presence  of  massive 
collapse,  159;  — ,  symptoms,  159; 
- — ,  treatment :  by  aspiration,  if 
sterile  and  large,  160;  by  thoraco- 
plasty, removal  of  foreign  body,  and 
cleansing  of  parts,  if  sepsis  likely  to 
ensue,  162;  special  indications  for 
operation,  163;  illustrative  case, 
showing  value  of  method,  164 

Haemothorax  occurring  in  civil  life, 
157;  — ,  aetiology  of,  157;  — >  symp- 
toms, 158;  — ,  treatment,  158 

Hair-combers  of  Paris,  aspergillosis 
amongst,  414 

Haldane,  J.  S.,  and  Douglas,  C.  G.,  on 
absorption  and  secretion  of  oxygen 
by  the  lungs,  5 

Halliburton,  Professor  W.  D.,  on 
chemistry  of  pleural  effusions,  92 

Hallows,  Norman,  Abrahams,  A.,  and 
French,  H.;  see  under  Abrahams,  A  ., 
Hallows,  Norman,  and  French, 
Herbert 

Hamamelis,  tincture  of,  in  haemoptysis, 
704 

Hamilton,  Professor,  morbid  anatomy 
of  bronchitis,  180,  181 

Hammond,   J.  A.,   RoUand,  W.,  and 


776 


DISEASES   OF   THE    LUNGS   AND    PLEURA 


Shore,  T.  A.  G.,  on  purulent  bron- 
chitis, i86 

Hampstead  for  phthisical  patients  who 
have  regained  health,  669 

Hare,  C.  J.,  double  tapes  for  chest 
measurement,  23 

Harris,  J.  D.,  successful  treatment  of 
abscess  of  lung  by  drainage  and 
incision,  360 

Harrismith,  South  Africa,  climate  of, 
suitable  for  phthisis,  649 

Hartley,  P.  H.-S.:  bacterial  classifica- 
tion of  broncho-pneumonia,  325; 
climate  of  seaside  resorts  and  that 
of  inland  regions  compared  (the 
climate  of  the  Midland  counties), 
653)  670;  differences  in  climate 
between  Egyptian  health  resorts, 
665,  670;  relative  frequency  of  more 
important  complications  of  pul- 
monary tuberculosis  based  upon 
autopsies  at  Brompton  Hospital, 
532,  545;  size  of  opening  in  pneu- 
mothorax, 138;  table  showing  the 
frequency  of  occurrence  of  lardace- 
ous  disease  in  chronic  pulmonary 
tuberculosis,  and  the  organs  chiefly 
affected,  568,  572;  case  of  artificial 
pneumothorax  followed  by  rupture 
of  the  lung, 724 

Hartz,  the  actinomyces  or  ray  fungus, 

394 
Harz  Mountains  suitable  for  phthisis, 

65r 
Hastings,    chief   climatic   features    of, 

643,    659;    suitable    for    bronchitis, 

193;  — ,  for  phthisis,  654,  658 
HavUand,  wind  exposure  in  relation 

to  phthisis,  450 
Hay  asthma;  see  Hay  fever 
Hay  fever,  causation  and  symptoms, 

248;     treatment     and     prevention, 

261 
Headache   in   tuberculous  meningitis, 

565 

Health  resorts  for  pulmonary  tuber- 
culosis, 637-670  {see  Climatic  change 
in  treatment  of  pulmonary  tuber- 
culosis); in  chronic  bronchitis,  193, 
194,  665;  in  emphysema,  283;  suit-  j 
able  for  asthma,  256,  257,  664,  665;  | 
see  also  Great  Britain,  health 
resorts  of 

Heart:  disease  of,  a  cause  of  acute 
pulmonary  oedema,  577;  — ,  predis- 
posing to  bronchitis,  177;  displace- 
ment of,  in  haemothorax,  158,  159; 
— ,  in  hydatid  disease  before  rupture, 
369 ;  — ,  in  massive  collapse  of  lung, 
346,  348,  350;  — ,  in  mediastinal 
tumour,  742 ;  — ,  in  pleuritic  effusion. 


99;  — ,  in  pneumothroax,  143,  145, 
146 

Heart,  effect  of  chest  conditions  on, 
15 ;  failure  in  pneumonia,  316 

Hedges,  C.  E.,  on  the  tuberculous 
nature  of  acute  pleurisy  with 
effusion,  91 

Heliotherapy,  641;  in  surgical  tuber- 
culosis, 641 ;  in  tuberculous  peri- 
tonitis and  chronic  ulceration  of  the 
bowel,  697;  intralaryngeal,  in  tuber- 
culosis of  the  larynx,  698 

"Heliotrope  cyanosis"  in  influenzal 
pneumonia,  332 

Helwan,  feature  of  winter  climate  at, 
643,  664,  665;  winter  resort  for 
asthma,  chronic  bronchitis,  em- 
physema, and  quiescent  phthisis, 
193,  283,  664,  665 

Hendon,  healthy  suburb  for  arrested 
cases  of  phthisis,  669 

Henry,  H.,  and  Elliott,  T.  R.,  on 
haemothorax,  157,  160 

Henshaw,  Nathaniel,  "  Aero-Chalinos ; 
or,  A  Register  for  the  Air,"  281 

Hensley,  Philip,  on  mode  of  production 
of  first  respiration  in  new-born 
child,  6 

Hernia,  diaphragmatic,  r49;  see  under 
Diaphragm 

Heroin  in  asthma,  261;  in  cough  of 
phthisis,  689 

Herpes  in  pneumonia,  297,  310; 
zoster  and  intercostal  neuralgia, 
80,  82 

Hessian  railway  companies,  results  of 
sanatorium  treatment,  621 

Heymann,  Bruno,  ethnographical  data 
showing  phthisis  to  be  produced  by 
human,  not  bovine,  infection,  433 ; 
experiments  proving  that  inhaled 
tubercle  bacilli  enter  the  pulmonary 
alveoli,  428 

Highgate,  healthy  suburb  for  cases  of 
arrested  phthisis,  669 

Hilum  tuberculosis,  471-473,  575 

"  Himrod  "  powder  for  asthma,  259 

Hindhead  suitable  for  asthma,  256 

Hippocrates,  description  of  pleural 
friction,  60;  phthisis  described  by, 
420;  phthisis  ab  hcemopioe,  547;  the 
succussion  splash,  r33 

Hirt,  dust-producing  trades  and  bron- 
chitis, 178 

Hobart,  Tasmania,  climate  of,  656; 
for  phthisis,  657 

Hodgkin's  disease,  case  of  pseudo-" 
chylothorax  associated  with,  171 

Hoffmann,  F.  A.,  subsidence  of  symp- 
toms after  inhalation  of  foreign 
bodies,  234;  — ,  and  Musser,  table 


INDEX 


777 


of  statistics  as  to  foreign  bodies  in 

air-passages,  226 
Holden,  G.  W.,  case  of  pulmonary  and 

glandular  aspergillosis,  415 
Honeycomb  lung,  the,  211 
Home,  Jobson,  mode  of  invasion  of 

larynx  in  laryngeal  tuberculosis,  534; 

cause    of    loss    of    voice    in    early 

laryngeal  tuberculosis,  536 
Horse    and    asthmatic    attacks,    246; 

tuberculosis  in  the,  425 
Hort,  E.  C,  opsonic  index  in  phthisis, 

587 

Huancayo,  Peruvian  Andes,  for 
phthisis,  642 

Huggard,  W.  R.,  prevalence  of  tuber- 
culosis in  the  Canton  Grisons,  449 

Husbands,  consumptive,  effect  on 
wives,  437 

Hutchinson,  John,  calculation  of  costal 
movement  in  health,  11;  mechanism 
of  healthy  breathing,  9;  use  of 
spirometer,  26;  variation  of  vital 
capacity  with  age,  height,  and 
weight,  27;  — ,  and  Aron,  residual 
tension  of  lungs,  8 

Hydatid  cyst:  in  mediastinum,  734> 
737;  in  pleural  cavity,  378;  surgical 
treatment,  378 

Hydatid  disease  of  the  lungs,  367-378; 
age  and  sex  incidence  in,  geographi- 
cal distribution,  method  of  infec- 
tion, and  morbid  anatomy,  367,  368; 
before  rupture  of  cyst :  clinical 
features  of  the  disease,  with  illus- 
trative cases,  368-373;  course  of 
disease,  374-375;  death  of  cyst, 
rarity  of,  375 ;  diagnosis  by  physical 
signs,  X-ray  examination,  369;  — 
from  phthisis  and  pleural  effusion, 
375;  eosinophilia  and  complement- 
fixation  test  in,  370;  haemoptysis  in, 
368,  369;  treatment  of,  by  incision 
and  evacuation,  not  paracentesis, 
376,  377;  rupture  of  cyst  and  after, 
373;  excretion  of  cyst  membrane 
("gooseberry  skin"),  booklets,  and 
scolices,  374,  375;  simulating  ad- 
vanced phthisis,  375;  symptoms 
during  and  after  rupture,  373,  375; 
treatment  by  opening  and  draining 
cavity,    if    medicinal    means    fail, 

377 

Hydatid  thrill,  369 

Hydro-pneumothorax :  occurring  in 
cases  of  tuberculous  pneumothorax, 
140;  outlook  of,  148;  physical  signs 
of,  143;  — ,  movable  dulness,  143; 
— ,  succussion  splash,  143;  X-ray 
appearances,  147;  treatment,  152; 
— ,    by    paracentesis,    152;    — ,    by 


oxygen   replacement,    152;   see  also 
Pneumothorax 

Hydrothorax,  chemical  nature  of  fluid 
in,  92;  chronic,  following  pneumo- 
thorax, 148 

Hyeres,  climate  of,  661;  for  asthma, 
bronchitis,  and  emphysema,  193,  256, 
661 ;  for  phthisis,  661 ,  668 

Hygiene  of  the  nursery,  594;  of  the 
sick-room,  599,  600,  601 

Hyper-resonance,  39;  in  pneumo- 
thorax, 145 

Hyphomycetes,  or  mould  fungi:  and 
B.  tuberculosis,  422;  and  streptothrix 
group  of  organisms,  394;  and 
sporothrix  group  of  organisms,  411; 
occurring  in  bronchitis  in  tropical 
climates,  180 

Hysterical  dyspnrea,  150 

Ice-bag:  contra-indicated  in  haemop- 
tysis, 705;  in  pneumonia,  312,  315; 
in  tuberculous  meningitis,  709 

"  Ice-cradling,"  312 

Iceland,  hydatid  disease  of  the  lungs 

in, 367 
Ilkeston,  Lord,  danger  of  syncope  m 

pleurisy  with  effusion,  109 
Ilkley  for  asthma,  256,  257 
Immigration   laws    restricting   use    of 
climatic  change  and  sea-voyages  in 
treatment  of  phthisis,  636,  656 
India,  hill-stations  of,  climate  of,  651; 
North-West,  epidemics  of  pneumonia 
in, 289 
Indian  races,  varied  incidence  to  tuber- 
culosis in,  448 
Industrial  classes,  value  of  sanatorium 

treatment  among,  624,  625 
Infants,  acute  asthenic  bronchitis  in, 
danger  of,  184,  186;  bronchitis  in, 
at  first  dentition,  176 
Infection,  channels  of,  in  pulmonary 

tuberculosis,  427-433 
Infections,  secondary,  in  pulmonary 
tuberculosis:  see  Secondary  infec- 
tions 
Influenza:  complicated  by  bronchitis, 
179;  —  by  empyema,  130,  131;  - — 
by  pneumonia,  331-334:  bacterio- 
logy of,  331;  special  symptoms  and 
signs  of,  including  epistaxis,  hemop- 
tysis, "  heliotrope  cyanosis,"  and 
nephritis,  332;  treatment,  333; 
leading  to  acute  pulmonary  oedema, 
356;  to  asthma,  245;  to  increased 
activity  of  pulmonary  tuberculosis, 
468 
Injury  leading  to  chylothorax,  169; 
to  pneumonia,  288;  to  pulmonary 
tuberculosis,  450,  451 


778 


DISEASES    OF   THE    LUNGS   AND    PLEURA 


Inman,  A.  C,  effect  of  exercise  on 
opsonic  index,  612,  613;  observa- 
tions on  the  opsonic  index  in  active 
and  quiescent  phthisis,  585,  586;  on 
complement-fixation  test,  588 

Innsbnick  for  phthisis,  654 

Intercostal  fluctuation  in  pleural  effu- 
sion, 102;  in  hydro-  or  pyo-pneumo- 
thorax,  145;  neuralgia,  81 

International  Medical  Congress,  Lon- 
don, 1881,  38 

International  nomenclature  of  phj'sical 
signs,  44 

Interstitial  pneumonia,  335;  see  Pneu- 
monia, interstitial 

Intestines:  lardaceous  disease  of,  in 
phthisis,  567-569;  tuberculous  ulcera- 
tion of,  540;  — ,  appearance  of  site 
of  ulcers,  540-542;  — ,  attributable 
in  children  in  part  to  bovine  infec- 
tion, 433;  — •,  common  complication 
in  phthisis,  540;  — ,  perforation  of 
bowel  in,  541;  — ,  symptoms  of,  542- 
544;  constipation  in,  544;  diarrhoea 
in,  543;  — ,  treatment,  694-697 

Intrathoracic  growths;  see  Medias- 
tinum, tumours  of,  737  ;  and  Lungs, 
tumours  of,  750 

Iodine:  as  inhalant,  218,  681;  applica- 
tions [see  Counter-irritation);  in- 
tensive treatment  in  active  pul- 
monary tuberculosis,  678 

Iodoform  in  hectic  period  of  phthisis, 
678 

Ireland,  health  resorts  for  bronchitis, 

193 

Iron:  perchloride  of,  in  septic  and 
influenzal  pneumonia,  313,  333 

Irvine,  J.  Pearson,  primary  dilatation 
of  the  lung  following  bronchial  nar- 
rowing, 203 

Israel,  James,  published  first  case  of 
human  streptotrichosis  (actinomy- 
cosis), 394 

Italian  Lakes  in  spring  for  phthisis,  665 

Itard,  M.,  first  described  pneumo- 
thorax, 133 

Jaccoud  on  pneumothorax,  134 

Jackson,  Chevalier,  per-oral  broncho- 
scopy for  removal  of  foreign  bodies 
from  air-passages,  238 

Japan,  tuberculosis  in,  433 

Jauja,  South  American  Andes,  for 
phthisis,  642 

Jaundice  and  pneumonia,  296 

Jenner,  Sir  W.,  expiratory  theory  of 
eniphysema,  273 

Jewish  race  and  adenoid  growths,  177; 
lowered  phthisical  mortality  among, 
448 


Jeyes'  fluid  as  disinfectant,  600 
Johannesburg,  climate  and  description 

of,  649 
Johnson,  Sir  George,  case  of  feigned 

haemoptysis,  558 
Johnston,  Major  C.  A.,  tuberculosis  in 

the    different    races    composing    the 

Indian  Army,  448 
Jones,    Coppen,    on    the    streptothrix 

nature  of  the  Bacillus  tuberculosis , 

422 
Jones,  Varrier,  Medical  Superintendent 

of  the  Cambridgeshire  Tuberculosis 

Colony,  Papworth  Hall,  622 
Jones,  Wood,  tuberculosis  in  Egyptian 

mummy,  420 
Jourdanet,  D.,  effect  of  altitude  on  the 

treatment  of  phthisis,  449 
Jousset,    A.,    method    for    detecting 

tubercle  bacilli  in  pleural  fluid,  91 
Joy's  cigarettes  for  asthma,  260 
Jozeau's  capsules  in  chronic  bronchitis, 

192 

Kanthack,  A.  A.,  demonstration  of 
capsule  of  pneumococcus,  290 ; 
microscopical  appearances  of  bron- 
cho-pneumonia, 326 

Karroo  Tableland,  South  Africa,  for 
phthisis,  644 

Keith,  Arthur,  enlargement  of  the 
pulmonary  infundibula  in  emphy- 
sema, 270;  share  taken  by  the 
abdominal  muscles  in  normal  ex- 
piration, 9;  on  the  mechanism  of 
respiration,  345  ;  on  stethometry,  25 

Kelling  Sanatorium,  after-results  of 
treatment  of  phthisis  at,  621 

Kellock,  T.  H.,  foreign  body  in  left 
bronchus  successfully  treated  by 
pneumotomy,  234,  240 

Kelsch,  A.,  and  VaiUard,  L.,  on  tuber- 
culous nature  of  acute  pleurisy  with 
effusion,  91 

Kernig'ssign  in  tuberculous  meningitis, 
566 

Kidd,  Percy,  on  distribution  of 
Bacillus  tuberculosis  in  lesions  of 
phthisis,  426 

Killian,  introduction  of  bronchoscopy 
for  diagnosing  foreign  bodies  in  air- 
passages,  236,  237 

Kimberley  for  phthisis,  646 

King,  D.  Barty,  table  of  age-incidence 
in  bronchiectasis,  206 

King  Edward  VII.  Sanatorium,  Mid- 
hurst,  daily  routine  for  patients  at, 
608;  observations  on  mixed  and 
secondary  infections  in  pulmonary 
tuberculosis  at,  468;  percentage  of 
cases  of  early  phthisis  with  laryngeal 


INDEX 


779 


involvement,  534,  536;  practical  re- 
sults of  tuberculin  treatment  at, 
715,  716;  standard  diets  at,  615 

Klein,  E.,  pathology  of  lymphatic 
system  of  lung,  18;  reports  on  public 
telephones  and  tuberculosis,  435 

Koch,  R.,  discovery  of  tubercle 
bacillus,  474;  introduction  of  sub- 
cutaneous    tuberculin     test,     578, 

579 
Kohlisch,  dried  sputum  the  chief  source 

of  infection  in  phthisis,  429 
Koster    and    Allard    on    tuberculous 

pleurisy,  91 
Koumiss  cure  at  Meran,  651;  in  acute 

ulceration   of   bowel,    695,    697;    in 

pulmonary   tuberculosis,    602,    603; 

method  of  preparing  at  home,  603 
Krawkow,  experimental  production  of 

lardaceous  disease,  569 
Kronig's  sign  in  tuberculosis  of  lungs, 

502 

Labour,  graduated,  in  sanatorium 
treatment,  610-613 

Lactation,  danger  to  phthisical  mother 
from,  701,  702 

Lactic  acid  in  laryngeal  tuberculosis, 
699 

La  Cumbre,  Argentine,  suitable  for 
consumptives,  650 

Ladybrand,  South  Africa,  climate  of, 
648 

Laennec,  bronchial  breathing,  53; 
cicatrisation  of  lung  cavities,  528, 
529;  classification  of  adventitious 
sounds,  56;  —  of  varieties  of  bron- 
chitis, 194;  description  of  dry 
crackle,  59,  60;  discoverer  of  aus- 
cultation, 35;  infection  of  tuber- 
culosis conveyed  by  inoculation,  427; 
inspiratory  theory  of  emphysema, 
273;  laryngeal  and  tracheal  breath- 
ing, 54,  55;  metallic  tinkling,  58; 
mucous  rale,  41,  56,  57;  phthisis 
a  specific  disease,  474;  pleural 
friction,  60;  pneumothorax,  simple 
or  essential,  133,  134;  prognosis  as 
to  duration  of  consumption,  625; 
specific  nature  of  tubercle,  421; 
vesicular  murmur,  49 

Laingsburg,  South  Africa,  for  phthisis, 
644 

Langenbeck,  von,  first  observer  of 
parasite  of  streptotrichosis,  394 

Lardaceous  degeneration  in  phthisis, 
567-569;  — ,  organs  affected  and 
symptoms,  568,  569;  — ,  pathology 
of,  568;  — ,  in  empyema,  125;  ■ — , 
experimental  production  of,  569 

Laryngeal  breathing,  54,  55 


Laryngeal  tuberculosis;  see  Larynx, 
tuberculosis  of 

Larynx:  as  generator  of  the  bronchial 
breath-sound,  54;  foreign  bodies  in, 
223-227;  malignant  disease  of,  538, 
539;  syphilis  of,  538;  voice-sounds 
produced  by,  6r 

Larynx,  tuberculosis  of,  533;  affection 
of  voice  in,  536;  anaemia  of,  534; 
complicating  pulmonary  tubercu- 
losis, 534;  diagnosis,  537;  — ,  from 
alcoholic  or  irritative  catarrh,  537; 
— ,  from  hysterical  aphonia,  537,  538 ; 
■ — ,  from  malignant  growths  of,  539; 
■ — ,  from  smoker's  catarrh,  537;  — , 
from  syphilis,  537,  538;  frequency 
of  occurrence  in  phthisis,  533,  534; 
laryngological  appearances  in,  534, 
535;  morbid  lesions  found  post- 
mortem in,  533;  sex-incidence  in, 
533;  symptoms,  536;  treatment  of, 
697-701;  - — ,  by  absolute  silence  and 
checking  of  cough,  698;  — ,  by 
medicinal  means,  699-701 ;  ■ — ,  of 
cough,  701;  — ,  of  dysphagia,  699, 
7or ;  — ,  caution  as  to  use  of  local 
applications  and  surgical  inter- 
ference in,  698;  — ,  on  sanatorium 
lines,  698;  — ■,  tracheotomy  in,  701; 
tuberculous  tumours  in,  535,  538; 
ulceration  of  trachea  and  bronchi  in, 
535, 536 

Las  Palmas,  Canary  Islands,  for 
phthisis,  667 

Las  Vegas,  New  Mexico,  for  phthisis, 
642 

Lausanne  for  phthisis,  651 

Lead-mining  and  phthisis,  455 

Lebert,  Professor,  first  description  and 
illustration  of  parasite  of  strepto- 
trichosis, 394;  on  grape  cure,  604; 
on  plastic  bronchitis,  196 

Le  Damany  on  tuberculous  nature  of 
pleurisy  with  effusion,  91 

Leduc's  auto-insuftiator,  700 

Leeches  as  foreign  bodies  in  air- 
passages,  225;  in  treatment  of 
acute  pulmonary  oedema,  356;  —  of 
pleurisy,  107,  709;  —  of  pneumonia, 
312 

Lees  on  treatment  of  phthisis  by 
antiseptic  inhalations,  681 

Lendon,  A.  A.,  hydatid  disease  of  the 
lungs,  367,  375 

Leprosy,  acid-fast  bacillus  of,  423, 
424 

Leptothrix  in  sputum,  76 

Les  Avants  for  phthisis  in  spring,  669 

Les  Moulins  (Monaco),  climate  suit- 
able for  phthisis,  662 

Leucocytes  in  sputum,  70,  71 


780 


DISEASES    OF   THE   LUNGS   AND   PLEURA 


Leucocytosis  in  bronchiectasis,  216; 
in  cavitation  stage  of  phthisis,  503; 
in  empyema,  121 ;  in  pneumonia, 
298-299,  476;  in  tuberculous  menin- 
gitis, 567 

Leucopenia  in  acute  pneumonic 
phthisis,  476;  in  early  stages  of 
phthisis,  503 

Levaditi  on  streptothrix  nature  of 
Bacillus  tuberculosis,  422 

Leyden,  E.,  pyo-pneumothorax  sub- 
phrenicus,  149 

Leysin,  Alpine  station  for  treatment 
of  surgical  tuberculosis,  641 

LUlingston  and  Pearson,  Vere,  ap- 
paratus for  artificial  pneumothorax, 
720 

Lipoma  of  lung,  750;  of  mediastinvma, 

737 

Lister,  F.  S.,  varieties  of  pneumo- 
cocci  in  pneumonia  amongst  South 
African  natives,  291,  292 

Living  bodies  {Ascaris  lumbricoides , 
etc.)  in  air-passages,  225 

Llandudno  for  bronchitis,  193 

Lobelia,  ethereal  tincture  of,,  in 
asthma,  259 

Lobular  inflammation  of  lung  [ses 
Broncho-pneumonia),  323 

Lobules  of  lung,  3,  4 

London  County  Council  Report  on 
Phthisis  Death-Rates  in  Relation  to 
Overcrowding,  454 

London,  Regent's  Park,  climatological 
features  of,  643,  659,  660 

LongstafE,  G.  B.,  on  conjugal  tuber- 
culosis, 438;  on  pneumonia,  286 

Lord,  F.  T.,  micro-organisms  in  sup- 
purative pleurisy,  119 

Los  Angeles,  California,  climatological 
features  of,  643,  667;  suitable  for 
pleurisy,  119;  for  phthisis,  668 

Lotni  Bhowali  Sanatorivma,  India,  651 

Louis,  prognosis  on  duration  of  con- 
sumption, 625 

Lugano  for  phthisis  in  spring,  665 

Lumbar  puncture  in  tuberculous 
meningitis:  in  diagnosis,  567;  in 
treatment,  710 

Lung,  abscess  of,  359  {see  Abscess  of 
lung);  cirrhosis  of,  335  {see  Pneu- 
monia, interstitial);  collapse  of  {see 
Collapse  of  lung),  344;  honey- 
comb, 211;  tumours  of,  750;  • — ■, 
innocent,  750;  — ,  malignant,  750- 
752;  — ,  physical  signs,  752;  — , 
symptoms,  751;  — ,  treatment,  752 

Lungs,  anatomy  and  functions  of, 
1-19;  13'mphatics  of,  18;  nerves  of, 
19;  state  of,  in  foetus,  6 

Luxor  for  phthisis  in  winter,  665 


Lyme  Regis  for  bronchitis,  193 

Lymphatics:  of  diaphragm,  liver,  and 
pleura,  connections  between,  19,  86; 
of  pleura,  connections  of,  85,  86; 
of  pleural  and  peritoneal  surfaces 
of  diaphragm,  communication  be- 
tween, 19;  pulmonar}',  18;  — ,  com- 
munication with  Ij'mphatics  of 
visceral  pleura,  18 

Lymphocytes  in  tuberculous  menin- 
gitis, 566 

Lyster,  A.  E.,  shelters  for  consump- 
tives, 622 

MacAlister,  Alexander,  size  of  lumg 
lobules,  4;  estimation  of  number  of 
pulmonary  alveoli,  50 

MacCormac,  Henry,  foreshadowed 
sanatoria,  607 

MacDonneU,  pulsation  of  fluid  in 
suppurative  pleurisy  (empyema  pul- 
sans),  122 

Mackenzie,  Hector,  statistics  of  pneu- 
monia and  its  complications,  307 

MacLeod,  J.  J.  R.,  and  Bullock,  W., 
acid-fastness  of  Bacillus  tuberculosis, 

423 

Madeira,  climate  of,  643,  665,  666; 
suitable  for  bronchitis  and  emphy- 
sema, and  phthisical  patients  with 
irritable  cough  and  early  laryngeal 
trouble,  283,  666 

Madison,  Franz,  reaction  to  tuberculin 
test,  582 

Malaga  for  phthisis,  663 

Malvern  for  asthma,  256;  for  bron- 
chitis, 193;  for  phthisis,  653 

Manitou  Park,  Colorado,  for  phthisis, 
642 

Maragliano  serum  for  tuberculosis,  717 

Marcet,  W.,  mean  relative  winter 
humidity  at  Cannes,  660 

Mare's  mUk  in  phthisis,  603 

Margate  for  autumn  treatment  of 
phthisis,  653;  for  recovery  from 
empyema,  130 

Marine,  maritime,  and  inland  climates 
for  phthisis,  653-670 

Marital  or  conjugal  tuberculosis,  437 

Marmorek  serum  for  tuberculosis,  717 

Marshall,  M.  I.,  and  Craighead,  J.  W., 
perforation  of  rupture  of  lung  fol- 
lowing artificial  pneumothorax,  724 

Martin,  Sidney,  experimental  tuber- 
culosis in  pigs,  430 

Massive  collapse  of  lung,  345;  see 
Collapse  of  lung,  massive 

Masson,  A.,  and  Schulmann,  M.  E., 
case  of  pulmonary  sporotrichosis,  412 

Maunsell,  Surgeon-Major,  epidemics  of 
pneumonia  in  North-West  India,  289 


INDEX 


781 


Measles  and  bronchitis,  179;  and 
broncho-pneumonia,  323;  followed 
by  acute  tuberculosis,  184 

Meat  juice,  raw,  method  of  prepara- 
tion, 617 

Mediastinitis :  chronic,  736;  suppura- 
tive, 734;  —,  signs  of,  734;  — >  simu- 
lating intrathoracic  tumour,  748;  — , 
treatment,  735 

Mediastinum,  abscess  of,  734;  see 
Mediastinitis,  suppurative 

Mediastinum,  tumours  of  the,  737;  — , 
innocent,  737;  — ,  malignant,  737; 
diagnosis,  748;  illustrative  cases, 
744-748 ;  physical  signs,  741 ;  pressure 
symptoms,  739;  prognosis,  749; 
treatment,  750 

Medical  Research  Committee,  the,  457, 
629 

Medicated  baths  for  asthma,  256 

Meek,  W.  O.,  complement  fixation  test, 
588;  value  of  change  in  work  and 
environment  following  sanatorium 
treatment  among  the  working 
classes,  621 

Mehu,  analysis  of  fluid  in  chronic 
pleurisy  with  effusion,  93 

Melbourne  unsuitable  for  chest  dis- 
eases, 656 

Mellin's  food  for  consumptives,  617 

Mena  House,  near  Cairo,  winter  resort 
for  asthma,  bronchitis,  and  quiescent 
phthisis,  193,  665 

Mendelssohn's  theory  of  emphysema, 

273 

Meningitis:  in  pneumonia,  306-308; 
tuberculous,  563-567;  — ■,  aetiology: 
human  and  bovine  bacilli  in,  432; 
— ■,  diagnosis  by  lumbar  puncture, 
566:  by  character  of  cerebro-spinal 
fluid  and  presence  of  tubercle 
bacilli  in,  566;  — ,  illustrative  cases, 
563,  564;  — ,  insidious  onset  of,  564; 
— ,  symptoms,  565;  — ,  treatment, 
709 

Meningococcus,  types  of,  318;  treat- 
ment of  meningitis  by  appropriate 
monotypical  serum,  318 

Menopausal  sweatings,  vasomotor  an- 
gina, and  asthma,  interchangeability 
of,  247 

Menopause  and  asthma,  245 

Menstruation  and  spurious  haemop- 
tysis, 561 

Menthol  in  hay  asthma,  262;  in  relief 
of  cough  in  phthisis,  681 

Mentone,  climate  of,  643,  662;  for 
asthma,  256;  for  bronchitis  and 
emphysema,  193,  283;  for  phthisis, 
663,  668;  mean  winter  temperature, 
643,  659,  660 


Meran  for  grape  and  koumiss  cure, 
604,  651;  for  phthisis  in  spring,  651, 

665 

Mercury  in  asthma,  258;  in  pulmon- 
ary syphilis,  392;  in  tuberculous 
ulceration  of  bowel  with  tympanitis, 
695,  696; 

Mesenteric  glands,  tuberculosis  of, 
without  intestinal  lesions,  430; 
presence  of  bovine  bacilli  in,  433 

Metallic  echo,  43,  62;  tinkling,  42,  45, 
58;  — ,  in  pneumothorax,  143;  — , 
in  large  tuberculous  cavities,  149 

Metchnikoff,  E.,  on  streptothrix  forms 
of  Bacillus  tuberculosis,  422 

Meyer,  W.,  and  Sauerbruch,  pressure 
chambers  to  prevent  collapse  of  lung 
in  chest  operations,  162,  163 

Micrococcus  catarrhalis  in  bronchitis, 
179, 180;  in  broncho-pneumonia,  325 

Micrococcus  tetragenus  in  broncho- 
pneumonia, 325;  in  infected  haemo- 
thorax,  160;  in  sputum,  76 

Micro-organisms  in  sputum,  76 

Middlesburg,  South  Africa,  for  phthisis, 

645 

Midhurst;  see  King  Edward  VII. 
Sanatorium,  Midhurst 

Milk:  channel  of  infection  in  tuber- 
culosis, 431-433;  — .  danger  elimi- 
nated by  pasteurising  or  boiling, 
433;  fermented  {see  Koumiss);  in 
phthisis,  602;  in  sanatorium  diet, 
616;  malted,  for  consumptives, 
617,  695;  with  rum,  to  aid  morn- 
ing cough  in  phthisis,  673 

Miller,  W.  S.,  diagram  of  lung  lobule, 

2     ^ 

Milton,  Penn,  case  of  chylothorax,  170 

Miners,     gold,     lead,     and    tin,     and 

phthisis,    455,   456;    and    puenmo- 

koniosis,  338-342,  455 

"  Mist   bacillus,"    acid-fast   properties 

of,  424 
Mixed  infections  in  pulmonary  tuber- 
culosis; see  Secondary  infections 
Moddersfontein,        sanatorium        for 

phthisis  at,  644 
Moffat  for  phthisis  in  autumn,  653 
Moller  and  acid-fast  bacilli,  424 
Monrovia,   California,   sanatorium   at , 

668 
Montana  for  asthma,  256;  for  phthisis, 

637 
Mont  Dore,  256,  257;  for  bronchitis, 

194;  for  catarrhal  asthma,  256;  for 

phthisis,  669 
Monte  Carlo,  resort  for  phthisis,  662, 

668 
Monte      Estoril,     near     Lisbon,     for 

phthisis,  663 


782 


DISEASES    OF   THE    LUNGS   AND    PLEURA 


Montreux  autumn  resort  for  phthisis, 
654;  for  asthma,  256;  for  grape 
cure,  604 

Moorland  districts  in  autumn  for 
phthisis,  653,  689 

Morgan,  W.  Parry,  apparatus  for  arti- 
ficial pneumothorax,  720 

Morland  and  Riviere  on  method  of 
prescribing  tuberculin,  579 

Morphia  in  asthma,  260;  in  acute 
pulmonary  cedema,  356,  357;  in 
hcemoptysis,  703,  706;  in  pneu- 
monia (in  exceptional  cases),  312; 
in  tumours  of  the  mediastinum,  750 

Morse,  J.  L.,  recovery  from  tubercu- 
lous hydro-pneumothorax,  148 

Mouat,  T.  R.,  on  compression  of 
veins  in  intrathoracic  dermoids, 
380,  381 

Moulds  in  sputum,  76,  180;  see  also 
Streptotrichosis,  394;  Sporotrichosis, 
411;  and  Aspergillosis,  414 

Mountain  air  in  after-treatment  of 
empyema,  129 

Mouth  as  source  of  foetor,  192 ;  haemor- 
rhage from  mucous  membrane  of, 
a  cause  of  spurious  haemoptysis,  558- 
562;  hygiene  of,  in  pneumonia,  im- 
portance of,  316;  washes,  333 

Miiller,  I.  J.,  muscular  tissue  in  lung 
of  dog,  8 

Mummy,  Pott's  disease  in  Egyptian, 
419 

Mundesley  Sanatorium,  results  of 
treatment  at,  among  the  wealthier 
classes,  626 

Murmurs,  cardiac,  in  pleural  effusion, 
100;  respiratory  (see  Breath-sounds 
and  Fremitus) 

Murphy,  Sir  S.,  overcrowding  and 
tuberculosis,  454 

Muscarine,  constriction  of  bronchi  and 
asthmatic  attack  produced  by  ex- 
perimental injection  in  animals,  243 

Musser  and  Hoffmann,  F.  A.,  table 
relating  to  foreign  bodies  in  air- 
passages,  226 

Mussy,  Gueneau  de,  on  diaphragmatic 
pleurisy,  88 

Mustard  gas,  inhalation  of,  producing 
septic  broncho-pneumonia,  324 

Myalgia  of  muscles  of  chest-wall,  80 

"  Myelin  droplets  "  in  sputum,  72 

Naegei,  post-mortem  evidence  of  tuber- 
culosis, 447 
Nairn  for  phthisis  in  autumn,  653 
Napier,    New    Zealand,    for    phthisis, 

657 
Nasal    asthma,     249;     catarrh,     190; 
operations   leading   to   presence   of 


foreign  bodies  in  air-passages,  224; 
polypi  a  cause  of  asthma,  246 

Naso-pharyngeal  disease  and  asthma, 
246;  catarrh,  lotion  for,  190 

Natal,  climate  of,  646 

Nebiola  hyoscinae  co.  in  asthma,  260 

Needle  for  use  in  artificial  pneumo- 
thorax, 721 

Negro,  American,  liability  to  con- 
sumption, 448 

Neisser,  relative  frequency  in  Europe 
of  hydatid  disease  of  the  lung,  367 

Nelson,  New  Zealand,  for  phthisis,  657 

Neo-arsenobOlon  in  pulmonary  syphilis, 
392 

Neo-salvarsan  in  active  phthisis,  678; 
in  pulmonary  syphilis,  392 

Nephritis  complicating  pulmonary 
tuberculosis,  569;  in  influenzal  pneu- 
monia, 332 

Nerve-supply  to  lungs,  19 

Nervi,  Italian  Riviera,  for  phthisis,  663 

Netter  on  tuberculous  nature  of 
primary  sero-fibrinous  pleurisy,  91; 
on  bacteriology  of  empyema,  119; 
on  pneumococcus  in  saliva  of 
healthy  people,  292 

Neuralgia,  intercostal,  80,  81 

Neuritis,  peripheral,  as  complication 
of  pneumonia,  307,  309 

New-born  child  rarely  reacts  posi- 
tively to  tuberculin  test,  427 

Newquay  for  phthisis,  654 

Newsholme,  Sir  A.,  on  provision  of 
institutional  treatment  and  decline 
in  phthisis  death-rate,  440 

New  York,  incidence  in,  of  various 
types  of  pneumococci,  with  resulting 
mortality,  291 

New  Zealand,  climate  of,  657;  immi- 
gration laws  as  to  admission  of 
tuberculous  patients  into,  636;  suit- 
able for  phthisis,  656,  657 

Nice,  for  bronchitis,  193;  for  elderly 
patients,  662;  mean  winter  tem- 
peratiure  at,  643,  659;  rainfall  at, 
660 

Night-sweating  in  pulmonary  tuber- 
culosis, treatment  of,  683 

Nitrites  in  asthma,  259;  in  haemop- 
tysis, 703,  706,  707 

Nitre  fumes:  in  asthma,  259;  formula 
for  production  of,  259 

Nitrogen  formerly  used  in  production 
of  artificial  pneumothorax,  719 

Nitro-glycerine  in  asthma,  259;  in 
bronchial  compression  from  aneur- 
ism, 205 ;  in  haemoptysis,  704 

Nomenclature,  international,  of  physi- 
cal signs,  44 

Nordrach  Sanatorium  for  phthisis,  651 


INDEX 


783 


"Note"  obtained  by  percussion;  see 

under  Resonance 
Nottingham  Road,  Natal,  sanatorium 

for  phthisis,  644 
Nursery,  hygiene  of  the,  594 

Occupational  diseases  from  inhalation 
of  irritating  dusts,  178 

CEdema,  acute  pulmonary,  354;  aetio- 
logy, 114,  354-356;  albuminous 
expectoration  in,  354;  cause  of 
the  attack  a  relative  failure 
of  the  left  ventricle,  356;  irri- 
tant gas  poisoning  and,  356,  357; 
symptoms,  355;  treatment,  356,  357; 
— ,  chronic  pulmonary,  appearance 
of  lungs  in,  353;  due  to  disturbances 
of  circulation,  352;  due  to  morbid 
condition  of  blood,  352;  symptoms, 
353;  treatment,  354 

(Esophagus,  compression  of,  by  medi- 
astinal tumours  causing  dysphagia, 
740;  foreign  bodies  in,  or  malignant 
growths  of,  leading  to  suppurative 
mediastinitis,  734 

Ogle,  Cyril,  case  of  teratoma  of  lung, 
383 

Oidium  albicans  in  sputum,  76;  see 
Aphthous  condition  of  mouth,  7or 

Old  age  and  bronchitis,  177 

Oliver,  Sir  T.,  duration  of  life  in 
pneumokoniosis,  341 

Opium  and  lead  suppositories  in 
diarrhoea  of  phthisis,  697;  and  starch 
enemata  in  diarrhoea  of  phthisis, 
697;  see  also  Morphia 

Opsonic  index:  as  indication  of 
secondary  infection,  690,  718;  value 
in  diagnosis  of  pulmonary  tuber- 
culosis, 586,  587;  variations  of,  in 
active  phthisis  and  in  early  quiescent 
cases  following  exercise,  584-586 

Oracle,  Arizona,  for  phthisis,  642 

Orange  Free  State,  climate  of,  647 

Orange-rubin  stain  for  clubs  in  strepto- 
trichosis,  395 

Oratava  for  chest  diseases  in  winter, 
667 

Ormerod,  J.  A.,  case  of  chylothorax, 
170 

Orthoform  insufflation  in  laryngeal 
tuberculosis,  700 

Orthopnoea  in  pleuritic  effusion,  97 

Osier,  Sir  W.,  case  of  acute  suppurative 
tuberculous  pleurisy,  124;  "  chronic 
adhesive  tubercular  pleurisy,"  87 

Osteo-arthropathy,  pulmonary,   213 

Osteomyelitis  of  rib,  tuberculous,  84 

Osteo-  or  chondro-sarcomata  of  lung, 
751 

Otago,  New  Zealand,  for  phthisis,  657 


Otitis  media  in  pneumonia,  307,  309; 
of  tuberculous  origin,  539 

Overcrowding  and  tuberculosis,  454 

Oxygen:  and  gas  as  anaesthetic  in 
chest  operations,  and  in  cases  of 
chest  disease,  128;  in  performance 
of  artificial  pneumothorax,  7x9;  in 
treatment  of  acute  pulmonary 
oedema,  356,  357;  —  massive  col- 
lapse of  lung,  350;  —  mediastinal 
tumour,  750;  —  pneumonia,  314, 
318,  334 

"replacement"  in  cases  of  pleurisy 
with  effusion,  114,  131;  —  orhydro- 
pneumothorax,  152 

Oxted  suitable  place  near  London  for 
permanent  residence  for  phthisical 
patients  who  have  regained  health, 
669 

Paget,  Stephen,  case  of  migrating  or 
wandering  empyema,  125 

Paignton  for  phthisis  in  autumn,  654 

Palpation,  account  of,  and  how  em- 
ployed, 34,  35;  definition  and  signi- 
ficance of,  39;  international  nom.en- 
clature  relating  to,  44 

Papworth  Hall  colony  for  treatment 
of  phthisis,  622 

Paracentesis  thoracis:  in  chylothorax, 
170,  171;  in  hemothorax,  158;  in 
pleuritic  effusion,  109;  method  of 
performing,  no;  — ,  danger  of  acute 
oedema  of  lung  and  "  albuminous 
expectoration "  if  carelessly  per- 
formed, 114,  354;  not  permitted  in 
cases  of  hydatid  of  lung,  376 

Paragonimiasis  and  haemoptysis,  546 

Paraldehyde  in  bronchial  narrowing, 
205;  in  pneumonia,  316 

Paralysis,  post-diphtheritic,  and  mas- 
sive collapse  of  lung,  345 

Paraplegia,  functional,  following 
haemoptysis,  551 

Paravertebral  triangle  of  dulness,  104 

Parotitis  and  pneumonia,  307 

Pasadena,  California,  for  phthisis  in 
winter,  668 

Pasteur,  W.,  definition  and  description 
of  massive  or  lobar  collapse  of  lung, 
345-348 

Pasteurising  or  boiling  milk  as  a 
precautionary  measure,  433 

Paterson,  M.  S.,  system  of  graduated 
labour  introduced  at  Frimley  Sana- 
torium, 609,  610;  — ,  and  Kirkland, 
T.,  apparatus  for  disposal  of  sputum 
at  Brompton  Hospital,  601 

Pau,  climate  of,  664;  for  catarrhal 
asthma,  256;  for  phthisis,  669 

Pearson,  Professor  Karl,  "  assortative 


784 


DISEASES   OF   THE   LUNGS   AND   PLEURA 


mating "  an  important  factor  in 
conjugal  tuberculosis,  439;  bio- 
logical properties  of  the  tubercle 
bacillus  a  factor  in  explaining  the 
incidence  of  tuberculosis,  457,  458; 
on  inherited  diathesis  of  pulmonary 
tuberculosis,  445,  446;  probability  of 
tuberculosis  developing  in  offspring 
of  tuberculous  father  or  mother,  439 ; 
— ,  Pope,  E.  G.,  and  Elderton,  Ethel 
M.,  on  conjugal  tuberculosis,  438 

Pearson,  Vere,  and  LUlingston,  ap- 
paratus for  artificial  pneumothorax, 
720 

Pecioriloquie  aphonique  in  pleural 
effusions,  120 

Pectoriloquy  in  acute  pulmonary  tuber- 
culosis, 476;  in  bronchiectasis,  215; 
in  phthisical  cavities,  523;  whisper- 
ing, definition   and  significance  of, 

43,  61 
Pegli,  winter  health  resort,  663 
Penzance     for     bronchitis,     193;     for 

phthisis  in  winter,  658 
Peppermint  essence  in  aiding  expec- 
toration in  bronchial  narrowing,  205 
Percussion:  definition  and  significance 
of,    39;    first    employment    of    by 
Auenbrugger,       35 ;       international 
nomenclature,     44;     method     and 
description  of,  35-37;  note,  varieties 
of,   see   Resonance;    theory  of,   46; 
see  also  Auscultatory  percussion,  62 
Peribronchial    and    perivascular  lym- 
phatics, 18;  —  phthisis,  471 
Pericarditis     in    empyema,     125;     in 

pneumonia,  307,  308 
Perichondritis  of  sternum  and  ribs,  82 
Periostitis  of  sternum  and  ribs,  82 
Perisporacidffi,    familj-    of   moulds   to 
which  the  aspergilli  belong,  414;  see 
Aspergillosis 
Perls,  M.,  on  residual  tension  of  lungs, 

7,8 
Perlsucht  in  cattle,  425 ;  only  recently 
introduced    to    Japan    and    Faroe 
Islands,  though  human  tuberculosis 
long    rife,    433;     see    Tuberculosis, 
bovine 
Perry,    S.    J.,    and   Elderton,   W.    P., 
conclusions  as  to  value  of  tuberculin 
treatment  at  Adirondack  Sanitarium, 
717;    results    of    sanatorium    treat- 
ment, 625-626 
Petitjean,  G.,  and  Pic,  A.,  effects  of 
amyl  nitrite  upon  pulmonary  blood- 
supply,  703 
Petri     and     Rabinowitsch,     acid-fast 

butter  bacillus,  424 
Phagocytosis    more    active    with    low 
degree  of  pyrexia,  677 


Phenacetin,  use  of,  in  pyrexia,  679 
Phenazone,  use  of,  in  pyrexia,  679 
Philip,  Sir  R.,  ipecacuanha  in  haemop- 
tysis, 704 
Phosgene  poison  gas  and  acute  pul- 
monary cedema,  357 
Phthisic  galopante,  474 
Phthisis,    acute   pneumonic,   474,  475- 
487;     illustrative     cases,     481-486; 
recovery    from,     481;     temperature 
charts  of,  478,  480,  482,  485;  treat- 
ment of,  671;   — ,  basal,  470;  diag- 
nosis from  bronchiectasis,  216;  — , 
chronic,  502  (see   Tuberculosis,  pul- 
monar}',  chronic);    — ■,  fibroid,  511; 
chronicity  of,  516;  illustrative  case 
of  forty-three  years'  duration,  516; 
lardaceous  changes  in  various  organs 
in  late  stage  of,  519,  520;  prognosis, 
519;  symptoms  and  signs  of,  511; 
transition   from  chronic  pulmonary 
tuberculosis  to,  illustrative  case,  507- 
509;    — ,  florid  or    "galloping   con- 
sumption," 487;  especially  in  j'oung 
adults,  487;  illustrative  cases,  488- 
491;    rapid   progress    to    fatal    ter- 
mination, 491;  temperature  charts, 
490;     gold-miner's,     340-342;     — 
"laryngeal,"    533;    — ,    "peri-bron- 
chial," 471;  see  also  Tuberculosis 

Pic,  A.,  and  Petitjean,  G.,  effects  of 
amyl  nitrite  upon  pulmonary  blood- 
supply,  703 

Picken,  R.  M.  F.,  recovery  of  dis- 
charged phthisical  soldiers  without 
sanatorium  treatment,  624 

Picric  acid  stain  for  clubs  in  strepto- 
trichosis,  395 

Pietermaritzburg,  climate  of,  647 

Pigeon-breast,  causes  of,  78 

Pigeon-feeders  in  Paris,  aspergillosis 
amongst,  414 

Pigs,  tuberculosis  in,  425;  experi- 
mental, 430 

Pilocarpine,  experimental  injection  of, 
causing  constriction  of  bronchioles, 
244 

Pine  wool  in  bronchitis,  188 

Piorry's  pleximeter  and  plessor,  36 

Pirquet,  von,  cutaneous  tuberculin 
test,  578,  583,  590;  rarely  positive 
in  new-born  chUd,  427;  too  delicate 
for  use  in  adults,  583 

Pitt,  Newton,  primary  dilatation  of 
lung  following  pressure  on  bronchus, 
203;  cases  of  haemopneumothorax, 
158 

Pituitary  extract  in  pneumonia,  315; 
of  posterior  lobe  in  asthma,  259 

Plan  for  spending  twelve  months  away 
from  England,  657 


INDEX 


785 


Plasmon  in  tuberculous  ulceration  of 
bowel,  695 

Plastic  bronchitis,  196;  see  Bronchitis, 
plastic 

Pleura:  anatomy  and  description  of, 
85;  irrigation  of,  in  empyema  an 
exceptional  measure,  129;  lym- 
phatics of,  connections  of,  85,  86; 
mortar-like  fluid  in,  in  large  quanti- 
ties, 171 ;  oedematous,  how  produced, 
469;  separation  of  layers  of,  in 
indurative  piilmonary  tuberculosis, 
469;  thickening  of,  in  pulmonary 
tuberculosis,  469 

Pleural  effusion :  circumference  of  chest 
in,  102;  displacement  of  organs  in, 
99,  102,  103;  malignant  in  nature, 
743.  746,  749;  physical  sign  of 
cardinal  and  supplementary,  99;  see. 
Pleurisy 

Pleural  friction ;  see  Friction,  pleural 

Pleural  reflex,  722 ;  following  irrigation 
of  pleura,  129;  in  treatment  by 
artificial  pneumothorax,  722 

Pleural  shock,  722;  following  irriga- 
tion of  pleura,  129 ;  in  treatment  by 
artificial  pneumothorax,  722 

Pleurisy,  85-131;  "chronic  adhesive 
tubercular"  (Osier),  87;  — ,  dia- 
phragmatic, 88;  — ,  dry,  fibrinous, 
or  plastic,  86-89;  diagnosis  from 
pleurodynia,  81;  pathology  of,  87; 
symptoms,  88;  treatment,  89; 
variety  of,  diaphragmatic,  88;  — , 
hcBfnorrhagic,  115;  — ,  malignant, 
743.  746,  749 

sero- fibrinous,  acute,  90-116;  aetio- 
logy, tuberculous  nature  of,  in  most 
cases,  90-92;  chemical  pathology  of 
fluid  effused,  92-93;  cytology  of 
fluid  effused,  92;  diagnosis,  105; 
fluid  sometimes  blood-stained,  115; 
physical  signs,  cardinal  and  supple- 
mentary, of  pleural  effusion,  97- 
105;  prognosis,  106;  skodaic  re- 
sonance in,  103;  symptoms  of,  93; 
temperature  charts  of,  94-95;  treat- 
ment, 106;  in  early  stages,  106,  107; 
in  stage  of  effusion,  107;  para- 
centesis, 109;  indications  for  inter- 
ference in,  109;  method  of  perform- 
ing paracentesis,  no;  risk  of  acute 
oedema  of  lung  and  albuminous  ex- 
pectoration if  carelessly  performed, 
114,  354 

sero- fibrinous,  chronic,  114;  rare 
at  present  time,  114;  treatment 
by  oxygen  replacement,  114;  — , 
suppurative,  118-131;  see  Empyema 

Pleuritis  a  frigore,  90,  93;  see 
Pleurisy 


Pleurodynia,  causes  of,  79;  diagnosis 
of,  81;  treatment  of,  81 

Pleximeter,  description  of,  36;  use  of 
finger  as,  36 

Pneumatometry,  25-26 

Pneumococcus :  capsule  of,  demonstra- 
tion of,  290;  characters  of,  290; 
chief  causative  agent  of  lobar 
pneumonia,  290;  in  the  blood  in, 
291,  299;  in  sputum,  290;  producing 
many  complications  in,  306;  — 
types  of,  incidence  of  such  in  pneu- 
monia in  New  York  and  South 
Africa,  with  resulting  mortality  and 
prognosis,  291;  —  treatment  by 
appropriate  serum,  318;  in  broncho- 
pneumonia, 324,  325;  in  pulmonary 
tuberculosis,  467;  in  suppurative 
pleurisy,  case  percentage,  119;  in 
saliva  of  healthy  individuals,  292; 
in  serous  pleurisy  due  to,  91 

Pneumokoniosis,  cetiology,  338-340; 
due  to  inhalation  of  dust,  338;  dust- 
producing  occupations  causing,  340; 
prevalence  of,  declining,  340;  prog- 
nosis and  expectation  of  life  in,  341 ; 
symptoms,  340;  — ,  those  of  bron- 
chitis and  emphysema,  340;  — ,'with 
illustrative  case  of  gold-miner's 
phthisis,  341 
Pneumonia,  chronic  interstitial,  335 ; 
see  Pneumonia,  interstitial 

Pneumonia,  interstitial  (cirrhosis  of 
lung),  335;  aetiology,  335;  associated 
with  bronchitis,  pleurisy,  and  pul- 
monary inflammation,  335;  due  to 
inhalation  of  dust,  335;  clinical 
features  of,  337;  microscopic  find- 
ings and  morbid  changes  in,  335, 
336;  section  of  lung  showing  nuclear 
proliferation  in,  336;  see  also  Pneu- 
mokoniosis 

Pneumonia,  lobar,  or  "  croupous,"  286, 
320;  abscess  in,  305,  318;  atiology, 
286;  — ,  climatic  influences,  287;  — , 
individual  predisposition,  286;  — , 
injury,  288;  — ,  personal  infection, 
288;  — ,  pre-existing  diseases,  286; 
— ,  septic  influences,  288;  anatomy, 
morbid,  of,  292;  bacteriology  of, 
289;  — ,  predominant  role  of  pneu- 
mococcus in  {see  also  Pneumo- 
coccus); clinical  description  of  case, 
296;  crisis  in,  299,  300;  delayed 
resolution  in,  304;  diagnosis,  300; 
gangrene  in,  306,  318;  leucocyte 
count  in,  298,  299;  physical  signs 
in  the  various  stages,  296-300; 
portion  of  lung  affected  in,  295 ; 
prodromal  symptoms  of,  295,  296; 
purulent  infiltration  or  diffuse  sup - 

50 


786 


DISEASES    OF    THE    LUNGS    AND    PLEURAE 


puration  in,  295,  305;  severity  of 
the  disease  varying  mucti  in  different 
years,  309;  stages  of,  292-294;  — 
of  consolidation,  310,  313,  314;  — 
of  convalescence,  317;  —  of  crisis, 
316;  —  of  hyperaemia,  310,  311;  — 
of  resolution,  310,  317;  symptoma- 
tology, 295,  296;  temperature  in, 
293,  294,  296,  299,  300;  — ,  chart 
of,  298;  treatment,  alcoholic  stimu- 
lants in,  311,  313-315,  316,  317;  — , 
dietetic,  313,  314;  — ,  drugs  in, 
311-317;  —  of  complications,  318; 

—  of  pain,  312;  —  of  pyrexia,  311, 
312;  —  of  shock  during  crisis,  316; 

—  of  sleeplessness,  315,  316;  — , 
oxygen  in,  314,  315;  — ,  serum  in, 
"  monotypical,"  319;  — ,  method  of 
administration,  319;  — ,  risk  of  ana- 
phylaxis and  serum  sickness,  319;  — , 
vaccines  in,  320;  varieties  of:  con- 
tusional,  288;  creeping,  304;  hypo- 
static, 294;  influenzal,  305,  331,  334; 
latent,  304;  migratory,  creeping,  or 
wandering,  304;  septic,  288,  302, 
318;  — ,  with  illustrative  case,  302; 
traumatic,  288;  — ,  diagnosis  from 
hemothorax  and  massive  coUapse 
of  lung, i5o 

Pneumonia,  lobular,  323;  see  Broncho- 
pneumonia 

Pneumonomycosis,  disease  caused  by 
moulds,  414 

Pneumothorax,  r33-i55;  cBtiology,  133; 
pulmonary  tuberculosis  the  common 
cause  of,  133-136;  bell-sound  heard 
in,  62,  143;  communication  between 
lung  and  pleura,  patent  or  valvular, 
138,  139;  — ,  size  and  position  of 
opening,  138;  diagnosis,  148-150; 
— ,  from  asthmatical  dyspnoea,  150; 
— ,  from  diaphragmatic  hernia  and 
escape  of  stomach  and  colon  into 
chest,  149;  — ,  from  emphysema, 
149;  — ,  from  hysterical  dyspnoea, 
150;  — ,  from  large  pulmonary 
cavities,  149;  — ,  from  pyo-pneumo- 
thorax  subphrenicus,  r49;  — ,  from 
X-rays,  147,  149;  fluid  effused  into 
pleura  in,  nature  of,  140;  gas  effused 
into  pleura  in,  analysis  of,  139; 
intrapleural  pressure  in,  139;  local- 
ised or  partial  in  character,  149; 
metallic  tinkling  not  alone  signifi- 
cant of,  58;  physical  signs  in,  142- 
146;  prognosis:  in  cases  secondary 
to  phthisis,  147;  in  conditions  other 
than  phthisis,  148;    symptoms,  140; 

—  simulated  by  acute  pulmonary 
congestion  in  advanced  tuberculous 
disease,  142;  temperature  charts  in, 


141, 142;  treatment,  151-155;  — ,  by 
evacuation  of  air,  151;  — ,  by  para- 
centesis, 152;  — ,  by  opium,  151;  — , 
by  oxygen  replacement,  152;  — ,  of 
pyo-pneumothorax,  152-155;  see  also 
Hydro-  and  Pyo-pneumothorax  and 
Artificial  pneumothorax 

Pneumothorax,  artificial,  719 ;  see  Arti- 
ficial pneumothorax 

Pneumotomy,  239 

Pohl,  W.,  statistics  of  intrathoracic 
dermoids,  380 

Poirier,  P.,  and  Cuneo,  B.,  on  the 
lymphatics  of  the  lung,  pleura,  and 
diaphragm,  19;  on  the  connection  of 
the  lymphatics  of  the  lung  and 
pleura  with  those  of  the  chest  wall, 
85,86 

Poison  gas  and  acute  pulmonary 
oedema,  357;  and  septic  broncho- 
pneumonia, 324 

PoUactne  inoculation  for  hay  asthma, 
262 

PoUantin  in  treatment  of  hay  asthma, 
262 

Pollen,  cause  of  hay  asthma,  248; 
protein  present  in,  245 

Pollock,  J.  E.,  on  duration  of  life  in 
phthisis,  625 

Polypi,  nasal,  a  reflex  exciting  cause 
of  asthma,  246 

Ponfick  on  parasite  of  streptotrichosis, 

394 

Poore,  Vivian,  garlic  in  treatment  of 
bronchiectasis,  218 

Pope,  E.  G.,  Elderton,  Ethel  M.,  and 
Pearson,  Karl,  on  conjugal  tuber- 
culosis, 438 

Pope,  E.  G.,  and  Brown,  Lawrason, 
results  at  Adirondack  Cottage  Sani- 
tarium, 627 

Portofino,  Eastern  Riviera,  for 
phthisis,  663 

Potain's  aspirator,  description  and 
uses  of,  111-113 

Potassium,  iodide  of:  and  stramonium 
in  asthma,  192,  262;  in  aspergillosis, 
4r7;  in  chronic  bronchitis,  192;  in 
haemoptysis  with  syphilitic  cachexia, 
705,  706;  in  plastic  bronchitis,  200; 
in  pneumonia,  317;  in  pulmonary 
oedema,  354;  in  sporotrichosis, 
413;  in  streptotrichosis,  409;  — :, 
leading  to  spurious  haemoptysis, 
558  ;  in  tuberculous  meningitis, 
710 

"  Potter's  "  cure  for  asthma,  259 

Potters,  mortality  among,  from 
phthisis,  455 

Poultices  in  acute  bronchitis,  188;  in 
confluent  broncho-pneumonia,  329; 


INDEX 


787 


in  pneumonia,  312;  in  sero-fibrinous 
pleurisy,  107 
Powell,  Sir  R.  Douglas :  case  of  chronic 
tubercular  disease  of  the  lungs 
illustrating  one  mode  of  production 
of  thickening  of  the  pleura,  89,  473; 
"  Clinical  Lectures  on  Excavation 
of  the  Lung  in  Phthisis,"  531;  case 
of  deep  ulceration  of  ileum  in 
phthisis,  with  constipation  a  marked 
feature,  544,  545;  "Note  on  the 
Value  of  Baccelli's  Sign — Pectori- 
loquie  Aphonique — in  the  Differential 
Diagnosis  of  Pleural  Effusions,"  132 ; 
on  displacement  of  the  heart  in 
pleural  effusion,  100,  117;  "On  a 
Case  of  Actinomycosis  Hominis," 
410;  on  pneumothorax,  155;  "On 
Some  Effects  of  Lung  Elasticity  in 
Health  and  Disease,"  20,  156;  "  On 
the  Causative  Relations  of  Phthisis," 
460;  some  cases  illustrating  the 
pathology  of  fatal  haemoptysis  in 
advanced  phthisis-,  65,  520,  556; 
table  comparing  asthma  with  angina 
pectoris  vaso-motoria,  243,  268; 
"  The  Role  of  the  Cardio- Vascular 
System  in  Pulmonary  Tuberculosis," 
510,  556;  "  The  Use  of  Strychnia  in 
the  Vomiting  of  Phthisis,"  710; 
"  Three  Cases  of  Phthisis  with  Con- 
tracted Lung,"  520;  — ,  and  Lyell, 
R.  W.,  case  of  basic  cavity  of  the 
lung  treated  by  drainage,  220,  222; 
— ,  and  Mahomed,  Dr.,  sounds  met 
with  in  diseases  of  the  chest,  38, 
44;  — ,  and  Sturges,  Dr.,  case  of 
intrathoracic  dermoid  tumour,  381- 

383 

Precipitin  test  in  phthisis,  588 

Pregnancy,  effect  of,  upon  pulmonary 
tuberculosis,  701,  702 

Preobraschensky,  S.  S.,  mortality  from 
foreign  bodies  in  air-passages,  238 

Pressure  signs  in  pleuritic  effusion, 
102;  in  intrathoracic  tumours,  739; 
in  suppurative  mediastinitis,  734 

Prpmontogno  for  phthisis  in  spring, 
641 

"  Proposote  "  in  phthisis,  688 

Prune-juice  sputum,  68 

Prussian  and  Hessian  railway  com- 
panies, results  of  sanatorium  treat- 
ment, 621 

Psoas  abscess  following  untreated 
suppurative  pleurisy,  125 

Pterygoid  chest,  causes  of,  79 

Puerile  breathing,  40,  44,  51 

Pulmonary  osteo-arthropathy,  213 

Pulsation  of  fluid  in  suppurative 
pleurisy,  121 


Pulse  irregular    in    early   tuberculous 

meningitis,  566 
Pulvis  rhei  co.  in  asthma,  258 
Purley    for    permanent    residence    for 

phthisical  patients  who  have  regained 

health,  669 
Purpura,  hsemoptysis  in,  546,  547,  549; 

causing  chronic  pulmonary  oedema, 

353; 

Purulent  bronchitis,  186, 191 ;  see  under 
Bronchitis 

Pus  cells  in  sputum,  70 

Putrid  bronchitis,  192 

Pyaemia:  and  abscess  of  the  lung,  359; 
and  gangrene  of  the  lung,  363;  and 
septic  broncho-pneumonia,  323,  324 

Pyogenic  organisms,  for  presence  of, 
in  lesions  and  sputum,  see  individual 
diseases 

Pyo-pericardium  in  pneumonia,  308 

Pyo-pneumothorax :  setiology,  134, 135, 
148,  229,  231;  cases  occurring  in 
course  of  pulmonary  tuberculosis, 
140;  outlook,  148;  — ,  course  of 
disease  sometimes  prolonged,  with 
illustrative  case,  152-155;  physical 
signs  of,  143;  — ,  movable  dulness, 
143;  — ,  succussion  splash,  143; 
treatment,  152-155;  X-ray  appear- 
ances of,  147;  see  also  Pneumothorax 

Pyorrhoea  alveolaris  and  spurious 
hcemoptysis,  558;  treatment,  559 

Pyrenees  in  spring,  665 

Pyrexia  in  active  pulmonary  tuber- 
culosis, treatment  of,  676-680;  to 
some  extent  a  protective  factor,  677 

"  Quack  "  treatment  of  asthma,  254 

Quain,  Sir  R.,  aneurism  of  pulmonary 
artery,  548 

Quartz  dust,  danger  of  silicosis  from, 
340 ;  see  Pneumokoniosis 

Quevli,  Dr.,  spread  of  tuberculosis 
among  North  American  Indians,  435 

Quincke,  H.,  and  Garre,  C,  mortality 
after  surgical  treatment  of  gangrene 
of  lung,  365 ;  results  of  operation  on 
abscess  of  lung,  360;  results  of 
operation  for  hydatid  disease  of 
lung, 377 

Quinine  in  abscess  of  lung,  360;  in 
broncho-pneumonia,  330;  in  hectic 
periods  of  phthisis,  679 ;  in  influenzal 
pneumonia,  333;  in  nasal  catarrh, 
596;  in  pneumonia,  311,  314,  316, 
317;  salicylate  of,  in  asthma,  261 

Quito  for  phthisis,  642 

Rabbit,  tuberculosis  in,  425 
Rabinowitsch     and     Petri,     acid-fast 
butter  bacillus,  424 


788 


DISEASES   OF   THE    LUNGS   AND   PLEURAE 


Race-incidence  of  pulmonary  tuber- 
culosis, 448 

Radcliffe,  J.  A.  D.,  mixed  and  secon- 
dary infections  in  pulmonary  tuber- 
culosis, 468 ;  complement-fixation 
test,  588 

Radiography  and  radioscopy  in  chest 
disease,  64;  stereoscopic  method 
introduced  by  Sir  Mackenzie  David- 
son, 64;  value  of,  in  diagnosis,  64; 
see  also  X-raj's  in  diseases  of  the 
chest 

Radium  in  mediastinal  tumours,  750 

Ragatz  for  phthisis  in  spring,  641 

Rales,  bronchial,  definition  and  com- 
mon significance  of,  41,  42;  inter- 
national nomenclature  of,  45;  — , 
explanatory',  56-58;  varieties  of: 
bubbling,  41,  45,  56;  cavernous  or 
gurgling,  42,  45,  58;  — ,  in  abscess 
of  lung,  360;  — ,  in  gangrene  of  lung, 
364;  — ,  in  tuberculous  excavation 
of  lung,  523;  clicking,  42,  45,  57; 
crackling,  42,  57>  58;  crepitant,  42, 
45;  dxjy  41,  56;  moist  or  liquid,  41, 
56,  57;  rhonchi,  41,  45,  56;  sibilant, 
41,  45,  46;  sonorous,  41,  45,  56; 
suijcrepitant,  42 

Ramsgate  for  autumn  treatment  of 
phthisis,  653;  suitable  for  schools  for 
delicate  children,  594 

Ranking,  W.  I.,  recovery  from  case  of 
pneumothorax  apparently  due  to 
ruptured  emphysematous  bulla,  135 

Ransome,  Arthur,  monograph  on 
stethometry,  25 

Rapallo  for  phthisis  in  winter,  663 

Raulin's  medium  for  cultivation  of 
aspergilli,  416 

Ravaud  and  Widal  on  cytology  of  acute 
sero-fibrinous  pleuritic  effusions,  92 

Ray  fungus,  394 

Reclus,  P.,  surgical  treatment  of 
gangrene  of  the  lung,  365 

Regent's  Park,  meteorological  data  at, 

643>  659,  660 
Registrar-General's  Seventy-First  An- 
nual Report   on  Tuberculosis,  452, 

453.  461 
ReichenhaU,    Bavaria,    compressed-air 

baths  at,  281 
Relaxed   lung   note,  39,  98,  103;    see 

Resonance,  skodaic 
Renon,  L.,  on  pulmonary  aspergillosis, 

414;  on  treatment  of  aspergillosis, 

417 
Resonance:  defiiution  and  significance 
of,  39;  international  nomenclature, 
44;     explanatory     theory     of,     46; 
varieties  of,  39;  — ,  absence  of,  39,    ^ 
44;  — ,  amphoric,  39,  44;  — ,  dimin- 


ished or  impaired,  39,  44;  — , 
increased,  39,  44;  — ,  normal,  39;  — , 
skodaic  (relaxed  lung  note),  39;  in 
pleurisy  with  effusion,  98,  103;  in 
pnemnonia,  39;  — ,  tubular,  39;  — , 
tympanitic,  39,  44,  47;  — ,  vocal, 
61  ;  see  Voice-sounds.  See  also 
Percussion 

Respiration,  "  cog-wheeled,"  52;  dyna- 
mics of,  demonstrated  by  diagram 
model  of  chest  wall,  12-16;  divided, 
53;  function  and  mechanism  of, 
5-12;  — ,  costal  and  diaphragmatic 
factors  in,  345;  irregular,  in  early 
tuberculous  meningitis,  566 

Respiration  saccadee,  40;  see  under 
Breath-sounds 

Respirators,  oro-nasal,  various  forms 
of,  680,  681 

Respiratory  centre,  action  of,  6; 
movements,  mechanism  of,  5-17;  — , 
effect  upon  lesions  of  pulmonary 
tuberculosis,  469;  murmur;  seeunder 
Breath-sounds  and  Respiration 

Rest  in  treatment  of  phthisis,  607,  612, 
712 

Reynaud,  pleural  friction,  60 

Rheumatic  fever  and  acute  pulmonary 
oedema,  356 

Rhodesia,  climate  of,  650 

Rhonchi,  41,  45,  56;  see  also  under 
Rales 

Rib  mobilisation,  Wilms'  operation, 
in  bronchiectasis,  220;  in  phthisis, 

729 

Rice  boiled  with  milk  and  stained  in 
acute  ulceration  of  bowel,  694 

Rickets  and  broncho-pnemnonia,  330; 
and  deformity  of  chest  wall,  78 

Riesman,  D.,  on  acute  pulmonary 
oedema,  355 

Rigor  and  abscess  of  the  lung,  359; 
in  pleurisy,  93;  in  pneumonia,  292, 
295,  296 

Rindfleisch,  E.,  on  expansion  of  lungs 
in  emphysema,  270;  inspiratory 
theory  of  emphysema,  274;  theory 
to  explain  enlargement  of  bronchial 
and  other  cavities,  527 

Riverina,  New  South  Wales,  for 
phthisis,  657 

Rivers,  W.  C,  statistics  of  pulmonary 
tuberculosis  at  Crossley  Sanatorixun, 
Delaware  Forest,  445,  446 

Riviera:  climate  of,  643,  659;  cloth- 
ing suitable  for,  661 ;  health  resorts 
along,  659-663;  mean  winter  tem- 
perature of,  659;  rainfall  of,  660; 
suitable  for  certain  cases  of  bron- 
chitis, 193,  660-663;  —  of  phthisis, 
660-663,  691 


INDEX 


789 


Riviere,  Clive,  on  artificial  pneumo- 
thorax, 720;  bacteriology  of  sup- 
purative pleurisy,  119;  hilum  tuber- 
culosis, 472;  special  pneumothorax 
needle,  721;  — ,  and  Morland,  on 
method   of    prescribing    tuberculin, 

579 

Roberts,  F.,  on  strapping  the  chest  in 
pleurisy,  89 

Rockefeller  Institute:  bacteriological 
findings  in  acute  lobar  pneumonia, 
290;  observations  on  types  of 
pneumococcus  met  with  in  pneu- 
monia, 291,  292;  presence  of  pneu- 
mococcus in  blood  in  pneumonia, 
299;  treatment  of  pneumonia  by 
monotypical  serum,  3r9 

Rocky  Mountains,  resorts  in,  for 
treatment  of  phthisis,  641-642 

Roe,  Hamilton,  on  paracentesis 
thoracis,  109 

Roentgen  rays,  63,  64;  in  chest  exami- 
nation, 64;  see  also  X-rays 

Roepke  and  Bandelier,  scheme  of 
tuberculin  dosage,  714,  716 

Rogers,  Sir  L.,  on  sodium  morrhuate, 
675 

Rokitansky  on  arrest  of  hjemorrhage 
in  haemoptysis,  555 

Rolland,  W.,  Hammond,  J.  A.,  and 
Shore,  T.  H.  G.,  on  purulent  bron- 
chitis, 186 

RoUier,  results  obtained  at  Leysin  in 
the  treatment  of  surgical  and  other 
forms  of  tuberculosis,  641 

Rome  unsuitable  for  phthisical 
patients,  669 

Rosenbach  on  grass-green  sputum,  68 

Rosewood  dust  causing  asthma  and 
bronchitis,  with  illustrative  case, 
178,  264 

Ross,  J.  N.  MacBean,  statistics  of 
cases  of  malignant  disease  of  the 
mediastinum,  749 

Rostrevor  for  bronchitis,  193 

Roumania,  tuberculosis  in,  433 

Royal  Commissions  on  tuberculosis, 
432 

Royat,  summer  health  resort,  669 

Ruffer,  Sir  A.,  and  Smith,  Professor 
Elliott,  Pott's  curvature  in  Egyptian 
mummy,  419 

Rum  and  milk  in  phthisis,  acute  first 
stage,  673 

Sabouraud's  glucose  media  for  isola- 
tion of  sporothrix  and  aspergUlus 
organisms,  411,  416 

Sahli  and  Trudeau,  reactionless  method 
of  administering  tuberculin,  716 

St.  Ann's  for  bronchitis,  193 


St.  Bartholomew's  Hospital:  after- 
history  of  cases  of  pleurisy  with 
effusion,  91;  bacteriology  of  em- 
pyema, 119;  mortality  from  lobar 
pneumonia  varying  from  year  to 
year,  309 

St.  Blasien  for  phthisis,  651 

St.  Leonards  for  chronic  bronchitis 
and  emphysema,  283 ;  for  permanent 
or  winter  residence  for  phthisis,  658; 
suitable  for  schools  for  delicate 
chUdren,  594 

St.  Mary  Church  for  asthma,  256;  for 
phthisis,  654,  658,  668 

St.  Moritz  for  asthma,  256 

Salines  in  haemoptysis,  705,  706 

"  Salisbury  "  dietary  in  asthma,  257 

Salisbury,  Rhodesia,  climate  of,  650 

Salt  and  water  in  haDmoptysis,  703 

Salter,  H.  H.,  on  asthma,  242,  245, 
249,  259;  on  the  elasticity  of  the 
chest  walls  on  inspiratory  force  in 
breathing,  9;  residual  tension  of 
lungs,  7 

"  Salubra "  paper  in  sick-room  of 
phthisical  patient,  599 

Salvarsan  in  pulmonary  syphUis,  392; 
in  phthisis,  678 

Sanatogen  in  acute  ulceration  of 
bowels,  695 

Sanatoria:  construction  of,  607;  in 
Denmark,  728;  in  England,  445,  609, 
611,  622;  in  Germany,  609,  621,  651; 
in  India,  651;  in  South  Africa,  644  ; 
in  Switzerland,  637;  in  United 
States,  627,  628;  see  also  Sanatorium 
treatment 

Sanatorium  treatment:  cases  suitable 
for,  606;  unsuitable  for,  626;  daily 
routine,  608;  diet,  6i3-6r7;  standard 
diet  in  use  at  the  King  Edward  VII. 
Sanatorium,  Midhurst,  614-616; 
exercise  and  work  in,  609;  detailed 
scheme  of  graduated  labour  at  the 
Brompton  Hospital  Sanatorium  at 
Frimley,  609-611;  importance  of 
efficient  after-care,  621;  with  hint's 
in  regard  io  change  of  work  and 
environment,  622-624;  results  of 
treatment,  619;  —  amongst  the 
industrial  classes,  619-626;  —  failure 
of,  in  advanced  cases,  620;  — 
amongst  the  wealthier  classes,  626- 
631;  see  also  under  Sanatoria 

Sandalwood,  oil  of,  in  bronchiectasis, 
218;  in  chronic  bronchitis,  192 

Sanderson,  Sir  J.  Burdon,  calculation 
of  costal  movement  in  calm  breathing 
during  health,  11;  origin  of  tuber- 
culous granulations  in  sheaths  of 
minute   bronchi,    465;    part   played 


790 


DISEASES   OF  THE   LUNGS   AND   PLEURAE 


in  pathology  by  lymphatic  system  of 
lung,  1 8 

San  Diego  for  phthisis  in  winter,  668 

Sanitas  for  use  in  sick-room,  599,  600 

San  Remo,  climate  of,  663;  mean 
winter  temperature  at,  643-659; 
spring  and  winter  treatment  of 
bronchitis  and  emphysema,  193, 
283;  —  of  phthisis,  663,  668 

Santa  Barbara,  California,  for  phthisis, 
668 

Santa  Cruz  for  asthma,  255,  667 

Santa  Fe,  New  Mexico,  for  phthisis, 
642 

Santa  Fe  de  Bogota,  Andes,  for 
phthisis,  642 

Sarcinse  in  sputum,  76 

Sarcoma  of  mediastinum  {see  Medias- 
tinum, tumour  of),  737;  of  lung,  751 

Sauerbruch  and  Meyer,  W.,  pressure 
chamber  to  prevent  collapse  of  lung 
in  chest  operations,  162,  163 

Saugman,  Professor  C,  artificial  pneu- 
mothorax, 719,  721,  722,  726; 
results  of  thoracoplasty  at  Vejlef  jord 
Sanatorium,  728 

Savin  ointment  in  secreting  cavities, 
690 

Scarborough  for  phthisis  in  autumn, 

653 
Schatzalp,  Davos,  Sanatorium,  637 
Schede's    operation    in     old-standing 

empyemata,  130 
Schenck,    B.    R.,    first    description    of 

sporotrichosis,  411 
Schizomycetes,  or  fission  fungi,  395 
Schmid,  altitude  and  tuberculosis,  449 
Schmorl,  primary  lesion  in  fine  bronchi 

in  early  phthisis,  429 
Scholberg,  H.  A.,   and  Wallis,   R.   L. 

Mackenzie,    on    true    and    pseudo- 

chylothorax,  166,  168 
Schools  for  delicate  children,  suitable 

seaside  localities  for,  594 
Schrotter,  von,  on  bronchoscopy,  237 
Schulmann,   M.   E.,   and  Masson,  A., 

case    of    pulmonary    sporotrichosis, 

412 
Schultze  on  streptothrix  forms  of  the 

tubercle  bacillus,  422 
Scolices     in     fluid     expectorated     in 

hydatid  disease  of  the  lungs,  374 
Scurfield,  H.,  on  excessive  mortality 

in    Sheffield    from    phthisis    among 

grinders  and  cutlers,  455,  456 
Scurvy  a  cause  of  chronic  pulmonary 

oedema,  353 
Sea-bathing  in   spurious  haemoptysis, 

562 
Sea    climate,    characteristics    of,  con- 
trasted with  those  of  mountain  val- 


leys, 655;  voyages  as  a  precaution 
against  phthisis,  596,  597;  —  for 
hay  asthma,  256;  ■ — ■  in  treatment 
of  phthisis,  654-658;  — ,  legislative 
restrictions  as  to  landing,  656;  — 
not  ideal  form  of  treatment,  654, 

655 

Secondary  infections  in  pulmonary 
tuberculosis,  467,  468;  use  of 
vaccines  in,  690,  691,  718 

Selous,  F.  C,  climate  of  Mashonaland, 
650 

Semon,  Sir  F.,  and  Williams,  P. 
Watson,  treatment  of  foreign  bodies 
in  air  and  upper  food  passages,  237 

Serum  treatment :  in  asthma,  danger  of 
grave  anaphylactic  symptoms  fol- 
lowing, 246;  of  pneumonia,  319;  — 
by  monotypical  serum,  319;  sickness 
following  treatment,  319,  320;  of 
pulmonary  tuberculosis,  717 

Sharkey,    S.    J.,   acute  bronchiectasis ' 
(bronchiolectasis),  211 

Shattock,  S.  G.,  on  the  teratomatous 
nature  of  certain  intrathoracic  der- 
moid tumours,  383,  384;  evidence  of 
tuberculosis  in  early  Nubian  skele- 
tons, 420 

Shaw,  H.  Batty,  and  Williams,  G.  G. 
O.,  statistics  of  intrathoracic  der- 
moid tumours,  380,  381 

Sheep,  tuberculosis  in,  425 

Sheffield,  excessive  mortality  from 
phthisis  at,  among  male  workers  in 
certain  trades  (grinders  and  cutlers), 
456 

Shelters  for  consumptive  patients,  622 

Sherrington,  C.  S.,  on  share  taken  by 
the  abdominal  muscles  in  normal 
expiration,  9 

Shetland  Isles,  hydatid  disease  of 
lungs  in,  367 

Shock  in  pneumonia,  311;  pleural,  in 
irrigation  of  pleura,  129;  in  artificial 
pneumothorax,  722 

Shore,  T.  H.  G.,  Hammond,  J.  A.,  and 
Rolland,  W.,  on  purulent  bronchitis, 
186 

Sibilus,  41,  45,  56;  see  also  under  Rales 

Sicily  for  phthisis  in  spring,  665 

Sick-room,  hygiene  of,  600 ;  importance 
of  cleanliness  in,  601 

Siderosis  from  inhalation  of  iron  dust, 

340 
Sidmouth  for  bronchitis,  193 
Sierra  Madre,  California,  for  phthisis, 

668 
Silicosis  from  inhalation  of  quartz  dust, 

340 
Silvius,  early  observations  on  morbid 

lesions  of  phthisis,  420 


INDEX 


791 


Simon,  Sir  John,  on  specific  nature  of 
tubercle,  421 

Simons  Town,  South  Africa,  for 
phthisis,  644 

Sitzenfrey,  A.,  on  congenital  infection 
in  tuberculosis,  427 

Skegness  for  phthisis  in  autumn,  653 

Skoda  on  character  of  the  bronchial 
breath-sound,  53;  the  veiled  puff  in 
bronchiectasis,  215 

Skodaic  resonance,  39 ;  in  pleurisy  with 
effusion,  98,  103;  in  pneumonia,  39 

Smallpox  and  bronchitis,  179;  and 
gangrene  of  the  lung,  363 

Smegma  bacillus,  423,  424 

Smith,  Archibald,  on  altitude  and 
phthisis,  449 

Smith,  Professor  Elliott,  and  Derry, 
D.  E.,  caries  of  the  spine  in  early 
Egyptian  skeletons,  419 

Smith,  Professor  Elliott,  and  Ruffer, 
Sir  A.,  Pott's  curvature  and  hip 
disease  in  Egyptian  mummies,  419, 
420 

Smith,  S.,  successful  treatment  of 
abscess  of  lung  by  incision  and 
drainage,  360 

Smith,  Sir  T.,  parasite  of  strepto- 
trichosis,  394 

Smoking,  excessive,  causing  laryngeal 
catarrh,  537;  diagnosis  from  tuber- 
culosis of  larynx,  728 

Smyth,  R.  Mander,  personal  experi- 
ence of  galloping  consumption, 
481 

Sodium  morrhuate  injections  in 
phthisis,  675,  676 

Solmersitz,  F.,  on  aspergillosis,  416 

Somerset  East,  South  Africa,  climate 
of,  645 

Sorgo  on  mixed  infections  in  phthisis, 
468 

South  Coast  of  England  for  bronchitis, 
193 

Southend  suitable  locality  for  per- 
manent residence  near  London  for 
phthisical  patients  who  have  re- 
gained health,  669 

Southey's  trocar,  use  of,  in  pneumo- 
thorax to  relieve  air-pressure,  151 

Southport  for  bronchitis,  193 

Spa  for  asthma,  257 

Sphacelus  of  the  lung  in  pneumonia, 
306;  treatment  of,  318 

Spirocha3tes    in    pulmonary    syphilis, 

387,  389, 
Spirometer,  Hutchinson's,  26 
Spirometry,  26 
Spitta,    H.    D.,    reports    on    possible 

danger  of  public  telephones  in  the 

spread  of  tuberculosis,  435 


Spitting  and  the  spread  of  tuberculous 

infection,  435 
Spittoons  and  liquid  disinfectant,  600; 

varieties  of,  600 
Splash;  see  Succussion 
Spleen,   situation   and   physical   signs 

of  normal,  38 
Splenification  of  lung,  294 
Sponging  to  reduce  pyrexia:  in  hectic 

periods  of  phthisis,  679;  in  influenzal 

pneumonia,  333;  in  lobar  pneumonia, 

311 

Sporothrix  parasite  of  sporotrichosis, 

413 

Sporotrichosis:  characteristic  lesions  of, 
411,  412;  diagnosis  and  treatment, 
413;  illustrative  case,  411;  sporo- 
agglutination  test  in,  413;  symptoms 
resembling  phthisis,  412,  413 

Sporotrichum  Beurmanni,  411; 
Schencki,  411 

Spring  treatment  of  phthisis,  668 

"  Sputa  margaritacea  "  in  bronchitis 
sicca,  196 

Sputum:  adventitious  matters  in,  76; 
"  albuminous  "  or  "  serous  "  fol- 
lowing paracentesis  of  chest,  114; 
— ,  in  acute  pulmonary  oedema,  353, 
354;  apparatus  for  disposal  of,  601; 
Bacillus  tuberculosis  in,  76,  429,  574; 
— ,  cultivated  from,  424  [see  also 
Tubercle  bacillus);  bronchial  casts 
in,  69;  cells  in,  70;  contact  with 
mucous  membrane  resulting  in 
laryngeal  tuberculosis,  534;  con- 
sistence and  colour  of,  67,  68; 
crystals  in,  75  ;  Curschmann's  spirals 
in,- 74;  elastic  fibres  in,  72,  73;  — 
in  abscess  of  lung,  306,  360;  — -  in 
gangrene  of  lung,  306,  364;  —  in 
pulmonary  tuberculosis,  476;  ex- 
amination of,  66,  67;  foetid  character 
of,  in  bronchiectasis,  212 ;  —  "  foetid 
bronchitis"  192;  —  in  gangrene  of 
lung,  306,  364;  fragments  of  lung 
tissue  in,  75,  74,  306;  in  acute  pul- 
monary oedema,  353,  354  [see 
Albuminous  expectoration);  in 
asthma,  244,  252,  253;  in  bronchiec- 
tasis, 212,  217;  in  chronic  bronchitis, 
191;  in  false  hsemoptysis,  561;  in 
haemoptysis,  550;  in  hydatid  disease 
of  lung,  375;  in  gangrene  of  lung, 
364;  in  intrathoracic  growths,  739; 
in  pneumonia,  297,  299,  300,  306; 
in  purulent  bronchitis,  186;  in 
tropical  abscess  of  liver,  68;  in 
ulceration  of  larynx,  74;  inhalation 
of,  leading  to  spread  of  lesions  of 
phthisis,  470;  "  myelin  droplets  "  in 
72;   micro-organisms   in,    76;   num. 


792 


DISEASES    OF  THE    LUNGS   AND    PLEURA 


mular,  191;  prune-juice,  68;  quan- 
tity of,  67;  "  red-currant  jelly,"  739; 
source  of  infection  in  phthisis,  429; 
sources  from  which  derived,  66; 
swallowing  of,  a  cause  of  dyspepsia 
in  phthisis,  602 ;  tonsillar  casts  in,  74 

Ssamara,  Russian  Steppes,  for  koumiss 
treatment,  603 

Stadler,  Dr.,  mean  duration  of  life  in 
phthisis,  625 

Staphylococci,  for  presence  of  in 
lesions  and  sputum,  see  individual 
diseases 

Starch  and  opium  enema  for  diarrhoea, 
697 

Steam-kettle  in  acute  bronchitis,  188; 
in  broncho-pneumonia,  330 

Stenosis,  mitral,  and  chronic  pul- 
monary oedema,  352 

Stereoscopic  method  of  X-ray  exami- 
nation, 64 

Sternum,  injury  to,  causing  medias- 
tinal abscess,  734;  perichondritis  and 
periostitis  of,  82-84 

Stethometry,  25 

Stethoscope,  biaural  flexible,  48 

Stewart,  Sir  T.  Grainger,  treatment  of 
bronchiectasis  by  intralaryngeal  in- 
jections, 219 

Stimulants,  abstinence  from,  in  recur- 
rent haemoptysis,  707;  see  Alcohol 
and  Alcoholism 

Stokes,  W.,  foreign  bodies  in  air- 
passages,  223, 227 

Stomach  note  in  health,  38 

Stone,  theory  of  production  of  aego- 
phony,  62 

Stools,  detection  of  tubercle  bacilli  in, 

574,  590 
Stramonium  in  asthma,  192,  259-261 
Strapping  of  chest  in  pleurisy,  89,  709 
Streptococci,  for  presence  of,  in  lesions 

and  sputum,  see  individual  diseases 
Streptotrichosis  (actinomycosis)  of 
lung  and  pleura,  394;  age-incidence, 
407;  chief  features  of,  with  illustra- 
tive cases,  397-407;  feculent  odour 
of  sputum  in,  192;  history  of  disease, 
394;  mistaken  in  earlier  times  for 
cancer,  osteo-sarcoma,  or  tubercle, 
394;  pathological  analogy  of,  396; 
parasite  of,  394,  408;  — ,  distribution 
of,  396;  — ,  morphology  and  staining 
properties  of,  395 ;  pyaemic  form  of, 
408;  simulating  pulmonary  tuber- 
culosis, 396,  407;  temperature  chart 
of  case  of,  400;  treatment,  408;  — , 
medicinal,  surgical,  and  vaccine,  409 
Stridor  in  bronchial  narrowing,  204; 
in  malignant  mediastinal  growths, 
740 


Strophanthus  in  advanced  emphysema, 
280 

Strychnine:  in  cod-liver  oil,  675;  in 
night-sweating  of  phthisis,  684;  in 
pneumonia,  3r3,  315,  316,  334;  in 
vomiting  with  cough  in  phthisis,  708 

Sturges,  Dr.,  and  Coupland,  on  spread 
of  pneumonia  by  contagion,  289 

Sturges,  Dr.,  and  Powell,  Sir  R. 
Douglas,  intrathoracic  dermoid 
tumour,  381-383 

Succussion  splash,  definition  and  signi- 
ficance of,  42;  in  hydro-  or  pyo- 
pneumothorax, 143;  international 
nomenclature,  45;  in  total  excava- 
tion of  lung,  149 

Summer  treatment  of  phthisis  best  at 
home,  669 

Sun,  exposure  to  direct  rays  of, 
inimical  to  tubercle  bacUlus,  425 

Suppositories,  lead  and  opium,  for 
diarrhoea,  697 

Surgical  emphysema,  135,  284 

Sutton,  Sir  J.  Bland-,  sequestration 
dermoids,  379 

Sweating  in  pulmonary  tuberculosis, 
treatment  of,  683 

Swift,  J.  C,  absence  of  emphysema  in 
Foundling  Hospital  boys  trained 
for  regimental  bands,  273 

Swiss  Alpine  resorts  for  asthma,  256; 
for  phthisis,  637;  showing  diminished 
prevalence  of  tuberculosis  with  in- 
creasing altitude,  449 

Swithinbank,  Harold,  on  resistance  of 
Bacillus  tuberculosis  to  low  tempera- 
tures, 425 

Syphilis:  associated  with  pulmonary 
tuberculosis,  392,  393;  predisposing 
to  bronchitis,  177;  to  fibroid  changes 
in  lung,  336;  of  bronchi  in  secondary 
stage  of  disease,  385;  causing  bron- 
chial catarrh,  385;  simulating 
measles,  385;  treatment,  392;  —  in 
tertiary  stage,  385;  causing  ulcera- 
tion of  bronchi,  385;  and  later 
stenosis  and  bronchiectasis,  205, 
386;  simulating  mediastinal  tumour, 
748;  treatment,  392;  of  larynx,  389; 
diagnosis  of,  from  laryngeal  tuber- 
culosis, 538;  of  lung  in  acquired 
syphilis,  387;  formation  of  gummata, 
387-389;  haemoptysis  in,  546,  549; 
physical  signs  and  symptoms,  388, 
389;  suggesting  tuberculosis,  389; 
illustrative  case,  389-391;  tempera- 
ture chart  of,  391;  treatment,  392; 
—  in  congenital  syphilis,  causing 
"  white  pneumonia,"  387;  of  sternum 
and  ribs,  84;  causing  mediastinal 
abscess,  734 


INDEX 


793 


Syringe,  exploring;  see  Exploring 
syringe 

Syrupus  Allii  Aceticus  in  bronchiec- 
tasis, 218 

Tabarie,  compressed-air  bath,  28r 

Tcenia  echinococcus  and  hydatid  dis- 
ease of  the  lungs,  367 

Talamon,  discoverer  of  pneumococcus, 
289 

Tamworth  for  residence  for  phthisical 
patients  who  have  regained  health, 
669 

Tapes,  double,  for  chest  measurement, 

23,  34 

Tar  in  chronic  bronchitis,  192;  in 
secreting  cavities,  690 

Tar-water  in  bronchitis-kettle  in 
broncho-pneumonia,  330 

Tatham,  John,  death-rate  from 
phthisis  in  dusty  trades,  455 

Taylor,  Sir  Frederick,  on  mode  of 
production  of  aegophony,  62 

Tea-factory  cough,  r8o 

Teeth,  condition  of,  as  source  of 
fcetor,  192;  decayed,  a  cause  of 
spurious  haemoptysis,  562 

Teignmouth  for  phthisis  in  winter,  658 

Telephones,  public,  and  tuberculosis 
infection,  435 

Temperature,  taking  of,  relative  merits 
of  mouth  and  rectum  methods,  609 ; 
see  Pyrexia 

Tenby  for  bronchitis,  193;  for  phthisis, 
654,  658,  668 

Teneriffe  for  asthma  and  phthisis,  255, 
667 

Teratoma  of  lung,  380;  see  Dermoid 
tumours,  intrathoracic 

Theobromine,  cardiac  stimulant  in 
pneumonia,  315 

Thermogen  wool  in  treatment  of 
bronchitis,  188 

Thomas,  J.  Davies,  and  hydatid 
disease  of  the  lungs,  367,  374,  377 

Thompson,  J.  H.  R.,  and  Bardswell, 
N.,  results  of  sanatorium  treatment 
at  the  King  Edward  VII.  Sana- 
torium, Midhurst,  629;  results  of 
tuberculin  treatment  as  practised  at 
the  King  Edward  Sanatorium,  Mid- 
hurst, 716,  717 

Thomson,  Sir  StClair,  percentage  of 
cases  of  phthisis  in  the  various 
stages  showing^  laryngeal  involve- 
ment at  the  King  Edward  VII. 
Sanatorium,  534;  — ,  prognosis  of 
such  cases,  536 

Thoracic  recoil,  8-12;  reserve  capacity, 
12;  resilience,  10;  tension,  8-12;  see 
also  Chest  and  Chest  walls 


Thoracocentesis  leading  to  develop- 
ment of  bronchiectasis,  210 

Thoracoplasty  in  bronchiectasis,  220; 
in  phthisis,  728;  in  pyo-pneumo- 
thorax,  152  ;  in  suppurating  pleurisy, 
130;  see  also  Wilms'  operation 

Thrill  in  hydatid  disease,  369;  in 
pneumothorax,  145 

Thusis  for  phthisis  in  spring,  641 

Timothy  grass  bacillus,  acid-fast,  424 

Tin-miners,  mortality  from  phthisis 
among,  455 

Tobacco  in  asthma  powder,  259 

Torquay  for  asthma,  256;  for  phthisis 
in  spring,  autumn,  and  winter,  654, 
658,  668;  winter  climate  of,  643,  659 

Total  excavation  of  lung  in  phthisis 
simulating  pneumothorax,  149 

Trachea,  ulceration  of,  in  laryngeal 
tuberculosis,  535 

Tracheal  breathing,  40,  54 

Tracheotomy  for  removal  of  foreign 
bodies  from  air-passages,  237,  239; 
in  laryngeal  tuberculosis,  701 ;  lead- 
ing to  septic  bronchitis  and  broncho- 
pneumonia, 179,  323,  324 

Transvaal  Province,  climate  of,  649 

Traube  on  causation  of  pulsation  in 
empyema  pulsans,  122,  experiments 
on  thoracic  expansion,  9 ;  on  stomach 
note  in  pleural  effusion,  103 

Traumatic  pneumonia,  288;  tuber- 
culosis, 450, 451 

Traumatopnoea,  159 

Treadgold,  H.  A.,  on  the  significance 
of  Arneth's  blood-picture  in  pul- 
monary tuberculosis,  503,  504 

Trocar,  for  evacuating  air  in  cases  of 
pneumothorax,  151;  special,  for 
performance  of  artificial  pneumo- 
thorax, 721 

Trousseau,  danger  of  sudden  death  in 
cases  of  pleurisy  with  effusion,  106; 
emetics  to  arrest  haemoptysis,  704; 
on  foetid  breath  and  expectoration 
in  bronchiectasis,  2r2;  on  para- 
centesis thoracis,  109;  on  the  bell 
sound  or  bruit  d'airain,  62;  on  the 
significance  of  haemorrhagic  effusions 
into  the  pleura,  115 

Trudeau  and  Sahli,  reactionless  method 
of  administering  tuberculin,  76 

Tubercle  bacillus,  431;  acid-fast  pro- 
perties of,  423;  antiseptics  and,  676; 
avian  variety  of,  426;  biological 
characteristics  of,  424,  425 ;  bovine 
variety  of,  426,  433  (see  Tubercu- 
losis, bovine) ;  branching  forms  of, 
422 ;  channels  of  infection  [see  Tuber- 
culosis, channels  of  infection);  club 
formation   of,    422;    cultivation   of, 


794 


DISEASES    OF   THE    LUNGS   AND    PLEURA 


424;  — ,  from  sputum,  424;  distinc- 
tion of,  from  other  acid-fast  bacilli, 
424;  distribution  of,  in  the  lesions  of 
phthisis,  426;  hum.an  variety  of,  426; 
morphology  of,  422;  presence  of,  in 
cerebro-spinal  fluid  in  tuberculous 
meningitis,  367; — ,  in  empyema,  123; 
— ,  in  hydro-  andpyo-pneumothorax, 
140;  — ,  in  pleurisy  with  effusion, 
91 ;  — ,  in  pulmonary  tuberculosis, 
distribution  in  lesions  of,  426;  in 
blood,  427;  in  caseating  areas,  426; 
in  miliary  tubercles,  427;  in  sputum, 
426,  429;  in  stools,  427,  540,  574; 
staining  of,  423;  — ,  by  Ziehl- 
Neelsen  method,  423;  — ,  by  con- 
centration methods,  574;  "types" 
or  varieties  of,  described  by  Dr. 
Brownlee,  453 

Tuberculin:  dosage,  scheme  of,  714, 
715;  method  of  prescribing,  714, 
716;  patients  to  whom  it  may 
be  given,  715;  preparations  of : 
albumose-free  (A.F.),  713,  7i6; 
Beraneck's,  714;  Denys'  Bouillon 
Filtre  (B.F.),  713,  714;  bacillary 
emulsion  (B.E.),  713,  714;  New 
Tuberculin  Rest  (T.R.),  713,  714; 
Oberst  (T.O.),  713;  Old  (Tuber- 
kulin  Alt),  712;  tests:  conjunctival, 
583;  cutaneous  (von  Pirquet's),  583; 
subcutaneous:  dosage  for,  579; 
reaction,  focal,  582;  — ,  general, 
586;  temperature  records  of,  580, 
581 

Tuberculosis:  ancient  Egyptian  skele- 
tons showing  evidence  of,  419; 
aural,  539;  avian,  426;  bovine,  425; 
— ,  characteristics  of  bacillus,  426; 
— ,  disease  in  cattle  known  as 
"  Perlsucht,"  425;  — ,  varieties  of 
tuberculosis  in  man  attributable  to, 
432,  433 — ,  with  resulting  mortality, 
433;  bronchial  gland,  471,  472; 
channels  of  infection,  427;  — ,  con- 
genital, 427;  — ,  ingestion,  428;  — , 
through  milk  and  butter,  431;  — , 
inhalation,  428;  — ,  inoculation,  427; 
— ,  with  illustrative  case,  428; 
chylothorax  and,  169;  conjugal,  437; 
death-rate,  for  all  forms  of,  in 
England  and  Wales,  compared  with 
that  of  phthisis,  419,  452;  foetal, 
427;  "  hilum,"  471,  575;  intestinal, 
symptoms  of,  540;  — ,  treatment 
of,  694  {see  Intestines,  tuberculous 
ulceration  of);  laryngeal,  symptoms 
of  J  533;  — )  treatment  of,  697  {see 
Larynx,  tuberculosis  of);  marital, 
437;  miliary,  492  {see  under  Pul- 
monary   tuberculosis)  ;     pulmonary 


{see  Pulmonary  tuberculosis) ;  trau- 
matic, 450 
Tuberculosis,  pulmonary :  cstiology, 
419-462;  — ,  age-incidence  in,  453; 
— ,  alcohol  and,  456;  — ,  altitude 
and,  449;  — ,  asthma  and,  254;  — , 
Bacillus  tuberculosis  exciting  cause 
of,  421  {see  Tubercle  bacillus); 
butter  a  source  of  infection,  431 ;  — , 
channels  of  infection,  427;  con- 
genital, 427;  ingestion,  428;  inhala- 
tion, 428;  inoculation,  427;  with 
illustrative  case,  428;  — ,  climatic 
factors  in,  448;  — ,  constitutional 
liability,  444;  — ,  contagion,  ques- 
tion of,  433;  — ,  dampness  of  soil 
and,  449;  — ,  death-rate  from, 
gradual  decline  of,  until  1914,  453; 
— ,  diabetes  and,  486;  — ,  dusty 
employments  and,  455 ;  — ,  epi- 
demiological factors  associated  with, 
457;  — ,  hereditary  factor  in  (the 
tubercular  diathesis),  445;  — ,  in- 
fluenza and,  468;  — ,  injury  and 
(traumatic  tuberculosis),  with  illus- 
trative case,  450,  451;  — ,  marital 
relationship  and  (marital  or  con- 
jugal tuberculosis),  437;  — ,  mental 
unsoundness  and,  457;  — ,  milk  as 
source  of  infection,  431;  — ,  over- 
crowding and,  454;  — ,  personal 
infection  and,  434;  — ,  social  con- 
ditions and,  451;  — ,  syphilis  and, 
392 

Tuberculosis,  pulmonary,  anatomy, 
morbid,  and  pathology  of :  granula- 
tion of  tubercle,  the,  463 ;  — ,  tending 
to  undergo  caseation,  464;  — ,  fibroid 
degeneration,  465 ;  — -,  with  secon- 
dary fibrosis  of  lung,  467;  mechanical 
effects  of  the  rigid  chest  wall  and 
respiratory  movements,  469;  mixed 
and  secondary  infections  in,  467; 
site  and  spread  of  the  tuberculous 
lesions,  470;  with  consideration 
of  "  hilum  tuberculosis,"  or  "  peri- 
bronchial phthisis,"   471 

Tuberculosis,  pulmonary,  classification 
and  clinical  varieties  of:  acute 
pneumonic  phthisis  (syn.:  caseous 
pneumonia;  lobar  form  of  caseous 
tuberculosis),  475-487;  distinction 
from  lobar  pneumonia,  475-477; 
illustrative  cases,  481-486;  prognosis 
grave,  but  case  of  recovery  recorded, 
481 ;  temperature  charts  of,  478,  480, 
482,  485;  treatment,  671,  726 
{see  Treatment);  — ,  chronic  (syn.: 
chronic  phthisis) :  blood  changes  in, 
503;  blood-pressure  in,  504;  cavity 
stage    of,    521-531     {see    Cavities); 


INDEX 


795 


early  symptoms  and  physical  signs, 
502;     illustrative     case,      505-507; 
physical  signs   when   disease  fairly 
pronounced,   505,   5o6;   pyrexia  in, 
504;    thoracic    flattening    at    later 
stage,  with  compensatory  expansion 
of  sound  lung,    a  hopeful   sign  in 
prognosis,  506;  transition  to  fibroid 
phthisis,  507;  with  illustrative  case, 
508,  509  {see  Treatment);  — ,  fibroid 
phthisis,  511   {see  Phthisis,  fibroid); 
— ,  florid  phthisis  (syn.:   galloping 
consumption;  acute  broncho-pneu- 
monic form  o£  caseous  tuberculosis); 
anatomy,  morbid,  of,  487;  illustrative 
cases,  488-491 ;  occurrence  of  laryn- 
geal tuberculosis  and  pneumothorax 
in,  491 ;  progress  rapid  and  outlook 
most  grave,  488;  pyrexia  in,  with 
chart,    490;    — ,    sometimes     "  in- 
verse "  in  type,  488;  resemblance  of 
case  to  one  of  acute  miliary  tuber- 
culosis, 488;  symptoms  and  physical 
signs,  487,  488;  treatment,  671  {see 
Treatment);  — ,  miliary,  492:  diag- 
nosis from  acute  bronchitis,  184;  — 
from  enteric  fever,  493 ;  —  from  acute 
disseminated  phthisis  (florid  phthisis 
or     galloping     consumption),     489; 
difficulty     in      detecting     tubercle 
bacUli  in  the  sputum,  494;  duration 
of  disease,  496;  fatal  outlook,  492; 
illustrative  cases,  492,  494;  — ,  with 
temperature  chart,  495;  sometimes 
secondary  to  old-standing  pulmonary 
tuberculosis,    494;    treatment,    671 
(see  Treatment);  — ,  subacute  (syn.: 
pulmonary    tuberculisation) :    ana- 
tomy, morbid,   of,   497,   498;   illus- 
trative    case,     499-501 ;     insidious 
origin   and    progress    of,    498;    ob- 
scurity of  development  of  physical 
signs,  and  notable  dryness  of,  500; 
prognosis    grave    in,    497;    pyrexia 
slight  in,  498,  501;  treatment,  671 
{see  Treatment) 
Tuberculosis,     pulmonary,     complica- 
tions :  albuminuria,  569 ;  aural  tuber- 
culosis,  539;    fistula    in    ano,   571; 
haemoptysis,   546    {see  Haemoptysis, 
true);    intestinal    tuberculosis,    540 
{see Intestines);  ischio-rectal abscess, 
571;  lardaceous  degeneration,   567- 
569;  — -,  organs  affected  and  symp- 
toms,  568,   569;   — ,   pathology  of, 
568;    laryngeal    tuberculosis,     533- 
539    {see   Larynx,    tuberculosis    of); 
meningitis,  563-567  {see  Meningitis, 
tuberculous);  pleurisy,  dry,  709;  — , 
with    effusion,    90;    pneumothorax, 
133;  table  showing  the  relative  fre- 


quency of  the  more  important  com- 
plications occurring  in  chronic  pul- 
monary tuberculosis,  532 

Tuberculosis,  pulmonary,  diagnosis  : 
clinical  methods  of  the  first  im- 
portance— viz.,  early  physical  signs, 
573;  evening  temperature,  574; 
symptoms,  573;  opsonic  test,  583- 
587;  other  specific  tests  (at  present 
mainly  of  scientific  interest),  587, 
589;  — ,  agglutination  test,  589;  — , 
cobra-venom  test,  588;  — -,  comple- 
ment-fixation test,  587,  588;  — , 
precipitin  test,  588;  procedure 
adopted  by  authors,  589,  590; 
sputum,  examination  of,  for  presence 
of  tubercle  bacilli,  574;  — ,  by  con- 
centrative  methods,  574;  — ,  by 
routine  methods,  574;  tuberculin 
subcutaneous  test  (for  special  cases), 
579-583;  X-ray  examination,  575- 
578 

Tuberculosis,  pulmonary,  mortality  : 
death-rate  from,  in  England  and 
Wales  from  1859-19x8,  452,  453; 
total  mortality  from,  in  England  and 
Wales  in  1918,  419 

Tuberculosis,  pulmonary,  prognosis : 
arrest  of  prolonged  duration,  with 
illustrative  cases,  516,  652,  633; 
outlook  in  first  half  of  nineteenth 
century,  625 ;  deaths  after  sana- 
torium treatment  among  the  patients 
at  Industrial  Sanatoria,  620;  —  at 
the  King  Edward  VII.  Sanatorium, 
Midhurst,  629,  630;  — •  at  the 
Mundesley  Sanatorium  (wealthier 
patients),  626,  627;  varying  with  the 
clinical  type  of  the  disease:  fatal  in 
miliary  tuberculosis,  492;  grave  in 
acute  pneumonic  phthisis,  481; 
and  pulmonary  tuberculisation,  497; 
most  grave  in  florid  phthisis,  488 

Tuberculosis,  pulmonary,  treatment : 
by  artificial  pneumothorax,  719- 
728  {see  Artificial  pneumothorax); 
climatic, 636-670  {see  Climatic  change 
in  the  treatment  of  pulmonary 
tuberculosis);  dietetic,  601-603,  613- 
617;  general  and  preventive,  593- 
605 ;  — ,  need  of  hospital  beds  for 
advanced  cases,  440;  in  acute  stage, 
671-684;  in  chronic  and  fibroid  stage, 
691-692;  in  more  quiescent  period, 
687;  of  aphthous  mouth  and  throat, 
701;  of  cavities,  secreting,  689;  — , 
and  ulcerous,  691;  of  cough,  680- 
683;  — ,  with  vomiting,  708  {see 
Cough);  of  fistula  in  ano,  571;  of 
haemoptysis,  702-708  {see  Haemop- 
tysis,  true);   of  lactation,   701;    of 


796 


DISEASES   OF   THE    LUNGS   AND    PLEURiE 


lar5Tigeal  tuberculosis,  697-701  [see 
Larynx,  tuberculosis  of);  of  menin- 
gitis, 709;  of  night-sweatmgs,  683; 
of  pleurisy  with  effusion,  no;  — , 
dry,  708;  of  pregnancy,  701;  of 
pyrexia,  676;  of  ulceration  of 
bowel  in,  694-697;  of  vomiting 
with  cough,  708;  sanatorium,  606- 
617;  — ,  results  of,  619  {see  Sana- 
torium treatment);  specific  by  anti- 
tuberculous  sera,  717;  — ,  by  tuber- 
culin, 712-717  {see  Tuberculin);  — , 
by  vaccines,  680,  717,  718;  surgical, 
728;  — ,  by  drainage  of  cavities,  729; 
— ,  by  rib  mobilisation,  729;  — , 
by  thoracoplasty,  728;  sea-voyages 
in,  654-658;  therapeutic,  by  anti- 
pyretics, 679;  — ,  by  antiseptic  in- 
halations, 681;  — ,  by  arsenic,  676, 
677;  — ,  by  cod-liver  oil,  674;  — , 
by  creosote,  678,  687;  — ,byguaiacol, 
687;  — ,  by  intensive  iodine,  678;  — , 
by  iodoform,  678;  — ,  by  sodium 
cacodylate,  677,  678;  — ,  by  sodium 
morrhuate,  675 ;  — ,  by  tar  prepara- 
tions, 678 

Tucker's  asthma  cure,  260 

Tulp,  Nicholas,  on  bronchial  casts, 
69 

Tumours,  intrathoracic,  737;  medias- 
tinal, 737  {see  Mediastinum,  tumours 
of);  of  the  lungs,  750;  see  Lung, 
tumours  of 

Tunbridge  Wells  for  phthisis  in 
autumn,  653 

Turkish  baths  for  asthma,  257 

Turpentine,  confection  of,  with  ether 
and  ammonia  in  pneumonia,  315; 
in  bronchiectasis,  218,  706;  in 
chronic  bronchitis,  189;  in  hsemop- 
tysis,  704;  liniment  in  bronchitis, 
189 

Tyndall,  John,  on  properties  of  rarefied 
air,  283 

Typhoid  fever  and  acute  pulmonary 
oedema,  356;  and  bronchitis,  179; 
and  gangrene  of  the  lung,  363; 
periostitis  from,  83 

Tyrol,  Austrian;  see  Meran 

Uhlenhuth  and  Xylander,  antiformin 

method     for     detecting     tubercule 

bacilli,  574 
Ulceration  of  the  bowel,  tuberculous, 

540;  see  under  Intestines 
Ulcerous    cavities    in    phthisis,    530; 

treatment  of,  691 
Ultra-violet    rays,    destructive    power 

of,  upon  bacterial  organisms,  639; 

upon  the  tubercle  bacillus,  425 
United  States,  immigration  laws  as  to 


admission    of    tuberculous    patients 

into,  636 
Urine  in  pneumonia,  296,  297,  299 
Urticaria  and  asthma,  247 
Uterine     disturbances     and     asthma, 

247 

Vaccines  as  prophylactic  in  asthma, 
263;  in  chronic  bronchitis,  193;  in 
lobar  pneumonia,  320;  in  secondary 
infections  in  pulmonary  tuberculosis, 
680,  690,  691,  718;  in  streptotri- 
chosis,  409 

Vaillard,  L.,  and  Kelsch,  A.,  on  the 
tuberculous  nature  of  acute  pleurisy 
with  effusion,  91 

Vansteenberghe,  P.,  and  Grysez,  ex- 
periments on  channels  of  infection 
in  pulmonary  tuberculosis,  431 

Vapour  bath,  creosote,  in  bronchiec- 
tasis, 217, 218 

Varese,  spring  health  resort  for 
phthisis,  665 

Variola,  bronchial  haemoptysis  in,  549; 
followed    by    pulmonary    gangrene, 

363 

Vasomotor  angina,  menopausal  sweat- 
ing, and  asthma,  interchangeabUity 
of,  247 

Veal  tea  in  acute  ulceration  of  the 
bowel,  695 

Vegetable  astringents  of  value  in 
diarrhoea  resulting  from  tuberculous 
ulceration  of  bowel,  697;  dust  and 
bronchitis,  178 

"  VeHed  puff  "  of  Skoda,  215 

Vejlefjord  Sanatorium,  Denmark,  re- 
sults of  thoracoplasty  at,  728 

Venesection  in  acute  pulmonary 
oedema,  356,  357;  in  bronchitis  with 
failing  right  heart,  190;  in  rare 
cases  of  hasmoptysis,  705;  in  pneu- 
monia with  faUing  right  ventricle, 
312,  315 

Ventil-gerdusch  {bruit  de  drapeau),  in 
plastic  bronchitis,  199 

Ventnor  for  chronic  bronchitis,  193; 
for  phthisis,  634 

Vernet-les-Bains,  spring  health  resort, 
665 

Vichy  water  with  tar  preparations  in 
chronic  bronchitis,  192;  in  secreting 
cavities  in  phthisis,  690 

Vierordt,  observations  on  mobUity  of 
chest,  25 

Villemin,  observations  on  the  specific 
nature  of  tubercle,  421 

Virchow  on  "  white  pneumonia,"  or 
"  white  hepatisation,"  in  congenital 
syphilis,  387;  the  "  myelin  droplets  " 
in  sputum,  72 


INDEX 


797 


Viscera,  abdominal,  displacement  of,  in 
pleural  effusion,  99;  thoracic,  rela- 
tion to  chest  wall,  30,  31,  38 

Vision,  disordered,  in  tuberculous  men- 
ingitis, 564,  565 

Vital  capacity,  variation  with  age, 
height,  and  body  weight,  27 

Vocal  vibrations,  35,  39,  44;  fremitus, 
35j  39.  44;  resonance,  normal,  61; 
— ,  method  of  production  of,  61  (see 
Voice-sounds);  rest  in  laryngeal 
tuberculosis,  698 

Voice-sounds,  normal,  definition  of, 
43 ;  impaired  in  disease  of  larynx,  61 ; 
method  of  production  of,  61;  see 
also  ^gophony,  Bronchophony,  and 
Pectoriloquy 

Vomiting,  early  symptom  of  tuber- 
culous meningitis,  564,  565;  with 
cough  in  phthisis,  516;  — ,  treat- 
ment of,  516,  708 

Voyages,  654-658;  see  Sea-voyages 

Waldenburg,  L.,  apparatus  for  treat- 
ment of  emphysema  by  rarefied  and 
compressed  air,  281;  diminished 
force  of  expiration  in  emphysema, 
275;  method  of  pneumatometry,  26 

Wallis,  R.  L.  Mackenzie,  report  upon, 
and  analysis  of,  milky  fluid  from  a 
case  of  pseudo-chylothorax,  174; 
and  Scholberg,  H.  A.,  on  true  and 
pseudo-chylothorax,  166-168 

Walsh,  Joseph,  on  the  presence  of 
tubercle  bacilli  in  the  urine  of 
patients  suffering  from  advanced 
phthisis,  570;  on  the  presence  of 
tubercles  in  the  kidneys  of  patients 
who  have  died  of  chronic  phthisis, 
570 

Walsham,  H.,  researches  on  tuber- 
culosis of  the  tonsils,  430;  on  the 
use  of  X-rays  in  chest  examination, 
63,  64 

Walshe,  W.  H.,  on  haemoptysis  in  pneu- 
monia,310  ;  on  the  influence  of  gravity 
in  the  distribution  of  rales  in  bron- 
chitis, 183;  on  variations  in  health 
of  chest  measurements  and  expan- 
sion, 24,  25 

Walther,  Otto,  advocating  taking  of 
rectal  temperatures  in  phthisis,  609 ; 
overfeeding  and  walking  exercises 
as  practised  at  Nordrach,  609,  614 

Ward,  Ernest,  on  conjugal  tubercu- 
losis, 438 

Warwick,  Queensland,  for  phthisis,  657 

Washbourne,  J.  W.,  on  air-capacity 
of  upper  air-passages  and  of  bron- 
chial tract,  50 

Wassermann  test   and  sporotrichosis, 


413;  in  pulmonary  syphilis,  388,  392; 
see  also  Contplement-fixation  test 

Watson,  J.  Chandler,  and  Freeman, 
John,  on  the  anaphylactic  origin  of 
asthmatic  attacks  resulting  from 
hypersensitiveness  to  a  foreign 
protein,  245 

Wavy  cavernous  breathing,  52;  see 
under  Breath-sounds 

Weaning  of  children  advised  early  in 
phthisis,  593 

Weber,  F.  Parkes,  on  traumatic  pneu- 
monia, 288;  and  traumatic  tuber- 
culosis, 451 

Weber,  Sir  Hermann,  cases  of  infection 
of  wives  by  consumptive  husbands, 
437;  on  diaphaneity  and  diather- 
mancy of  air  in  high  altitudes,  638 

Weist,  J.  R.,  mortality  from  foreign 
bodies  in  air-passages,  238 

Welch,  Assistant-Surgeon,  on  epidemic 
of  pneumonia  among  troops  at  New 
Brunswick,  287 

Welch,  W.  H.,  on  causation  of  acute 
pulmonary  oedema,  356 

Wells,  J.  W.,  on  effect  of  cod-liver  oil 
upon  metabolism,  674 

West,  Samuel,  cases  of  primary  strep- 
tothrix  disease  (actinomycosis)  of 
lung  and  pleura,  407;  on  calcareous 
fluid  in  the  pleura,  171 ;  on  primary 
broncho-pneumonia,  323 

Westcliff  -  on  -  Sea  for  residence  of 
phthisical  patients  who  have  re- 
gained health,  669 

West  Indies,  voyage  to,  in  spring,  for 
patients  convalescent  from  acute 
chest  diseases,  669 

Westminster,  Orange  Free  State, 
climate  of,  648 

Wet-nurse  for  child  of  consumptive 
mother,  593 

Wethered,  detection  of  tubercle  bacilli 
in  case  of  acute  miliary  tuberculosis 
on  twentieth  attempt,  494 

Weybridge  for  asthma,  256 

Weymouth  for  phthisis  in  autumn,  654 

Whey  in  phthisis,  602 

"  White  hepatisation,"  or  "  white 
pneumonia,"  in  congenital  syphilis, 

387 
Whooping-cough  :  complicated  by 
bronchitis,  179;  — by  broncho-pneu- 
monia, 323,  328;  —  by  collapse  of 
lung,  344 ;  —  by  pulmonary  vesicular 
emphysema,  269;  —  by  surgical 
emphysema,  135;  followed  by  pul- 
monary tuberculosis,  595;  simulated 
by  foreign  body  in  air-passages, 
234 ;  use  of  emetics  to  avert  broncho- 
pneumonia, 329 


798 


DISEASES   OF   THE   LUNGS   AND    PLEURA 


Widal  and  Ravaut  on  cytology  of  acute 
sero-fibrinous  pleural  effusions,  92 

Wijeyeratne,  Dr.  F.  C.  de  F-,  on  personal 
infection  in  pulmonary  tuberculosis, 

434 

Wilks,  Sir  Samuel,  on  frequency  of 
occurrence  of  hEemoptysis  during 
night,  550 

Wnicox,  W.  H.,  analysis  of  Tucker's 
asthma  specific,  260;  and  Colling- 
wood,  B.  J.,on  the  use  of  oxygen  and 
absolute  alcohol  in  pneumonia,  315 

Williams,  C.  J.  B.,  on  the  contractility 
of  the  bronchioles,  243;  on  fine-hair 
crepitation,  description  of,  59; 
theory  of  the  percussion  note,  46; 
and  Bennett,  Hughes,  on  the  value 
of  cod-liver  oil  in  phthisis,  674; 
and  Williams,  C.  Theodore,  on 
hereditary  predisposition  to  con- 
sumption, 445 

WUliams,  C.  Theodore,  on  aerothera- 
peutics,  281;  on  cod-liver  oil,  its 
value  in  phthisis,  674;  on  health  of 
staff  at  Brompton  Hospital,  435, 
436;  on  mortality  from  phthisis  in 
pre-sanatorium  days,  625;  on  results 
of  treatment  in  the  high  Alps,  639; 
on  sea-voyages,  good  results  from, 
in  phthisis,  654;  unsatisfactory 
results  of  treatment  of  phthisis  at 
Madeira,  666 

Williams,  G.  E.  O.,  and  Shaw,  H. 
Batty,  statistics  of  intrathoracic 
dermoid  tumours,  380,  381 

Williams,  Leonard,  association  of  high 
blood-pressure  and  acute  pulmonary 
oedema,  355 

Williams,  O.  T.,  cod-liver  oil  and  its 
action  in  phthisis,  675 ;  and  Forsyth, 
C.  E.  P.,  the  influence  of  unsaturated 
fatty  acids  in  tuberculosis,  685 

Williams,  P.  Watson,  on  normal 
rhythmical  expansion  and  contrac- 
tion of  the  bronchioles  during  respira- 
tion, 8;  increased  expiratory  con- 
traction explaining  the  asthmatic 
paroxysm,  8,  243 ;  and  Semon,  Sir  F., 
treatment  of  foreign  bodies  in  air 
and  upper  food  passages,  237 

Williams,  Stenhouse,  on  the  vitality 
and  virulence  of  the  tubercle  bacil- 
lus, 424,  425 

Wilms'  rib-mobilisation  operation  in 
bronchiectasis,  220;  in  phthisis,  729 

Wilson,  J.  A.,  Bashford,  E.  F.,  and 
Bradford,  Sir  J.  Rose,  filter-passing 
virus  in  influenza,  187,  331,  332 


Wind,  influence  of,  on  phthisis,  450 

Winter  resorts  in  England  suitable  for 
phthisis,  658,  659 

Wives,  effect  of  consumptive  husbands 
upon,  4:J7 

Woillez  first  employed  cyrtometer,  24 

Woldingham  suitable  for  residence  for 
phthisical  patients  who  have  re- 
gained health,  669    - 

Wolff-Eisner  and  Calmette,  conjunc- 
tival tuberculin  test,  579,  583 

WoUstein,  Martha,  bacteriology  of 
broncho-pneumonia,  324,  325 

Wounds  of  the  chest,  157;  see  Hsemo- 
thorax 

Wright,  Sir  Almroth,  opsonin  test 
introduced  by,  583;  vaccines  in 
pneumonia,  320;  see  also  Vaccines 

Wynberg,  South  Africa,  for  phthisis, 
644 

X-rays  in  diseases  of  the  chest,  64;  in 
abscess  of  the  lung,  360;  in  aneurism 
of  the  aorta,  205 ;  in  bronchial-gland 
tuberculosis,  576;  in  bronchiectasis, 
216;  in  foreign  bodies  in  brorichus, 
232;  in  gangrene  of  the  lungs,  365; 
in  gold-miner's  phthisis,  342;  in 
hilum  tuberculosis,  474,  575;  -in 
hydatid  disease  of  the  lung,  369; 
in  interlobar  pleurisy,  124;  in 
mediastinal  tumour,  743,  749;  in 
pleurisy  with  effusion,  121;  in 
pneumokoniosis,  340,  342;  in  pneu- 
mothorax, 147;  in  pulmonary  tuber- 
culosis, 471,  575-578;  in  pyo- 
pneumothorax subphrenicus,  149; 
in  suppurative  pleurisy,  121;  treat- 
ment by,  of  intrathoracic  growths, 
750;  see  also  Radiography  and 
Radioscopy  in  chest  disease 

Xylander  and  Uhlenhuth,  antiformin 
method  for  detecting  tubercle 
bacilli,  574 

Yarmouth  for  asthma,  263 

Yeo,  Burney,  on  the  grape  cure  in 
phthisis,  605;  respirator  for  inhala- 
tion of  volatile  antiseptics  in 
phthisis,  680 

Yorkshire  moors  for  asthma,  257;  for 
phthisis  in  autumn,  653,  689 

Young,  R.  A.,  microscopical  report  on 
case  of  Hodgkin's  disease  associated 
with  pseudo-chylothorax,  174 

Ziehl-Neelsen  method  of  staining 
tubercle  bacilli,  423 


H.  K,  LEWIS   AND    CO.    LTD.,  28  GOWER   PLACE,  LONDON,  W.C.  I 


Date  Due 


FEB  2  Q 


195] 


